Providing Effective Feedback

by Monique L. Mounce, Pharm.D., PGY1 Pharmacy Resident, Johns Hopkins Bayview Medical Center

One of the toughest yet crucial aspects of being an instructor is providing effective and constructive feedback.  Whether you are inside or outside the classroom teaching, you will have the responsibility of providing feedback both praise and constructive at some point in your career.   Although it may be uncomfortable for some, there are many techniques to assist you with providing verbal and written feedback to a learner.  Personally, as a Doctor of Pharmacy student and now a resident, providing written and verbal feedback to preceptors or pharmacy students has been a struggle.   Like others, I am always afraid of hurting someone’s feelings. I believe the key to effective feedback is the timing and the environment in which the feedback is delivered.

Feedback is defined as information provided by an agent (teacher, peer, parent, self, or experience) regarding aspects of one’s performance, thus it is a consequence of performance.¹ Feedback should be structured to fill the gap between what is understood and what is expected of the learner.  Structured methods for providing feedback date back to the early 1900s when behaviorism was developed.  In behaviorist terms, “positive feedback” is positive reinforcement and “negative feedback” is punishment.  Although feedback is powerful, it is not always accepted.  Feedback can be accepted, modified, or rejected by the learner thus it does not necessarily reinforce actions despite behaviorist’s initial theories on how feedback shaped behavior.  Feedback methods vary based on timing, amount, mode, audience, and its content.  Furthermore, the content varies based on focus, comparison, function, valence, clarity, specificity, and tone (Table 1).¹

Table 1 - Feedback Strategies and Content

Feedback Strategy	Aspects	Recommendations
Timing	-When -How often -Where	Provide immediate feedback for incorrect facts Reserve criticism for appropriate timing and when there is privacy Suggest a different location other than your office to make learner more comfortable.
Amount	-Number of points to make -Elaboration	Prioritize: No more than 2 “lessons” in one session The smaller and more frequent, the better
Mode	-Verbal -Written -Electronic	In-person discussions are best to allow a conversation and to ensure understanding Electronic can be interpreted differently than intended. Use this with short remarks only
Audience	-Individual -Group/Class	Focused attention is best- avoids embarrassment Share the feedback if common among learners but be careful about “picking on” one person
Feedback Content	Aspects	Recommendations
Focus	-Process used for task -Work/actions itself -Student’s self-regulation -Student personally	Most effective- focus on the process used for task completion and observed behavior Avoid personal comments because it makes learner get defensive and reject feedback
Comparison	-To standard of work (criteria-specific) -To other students (norm-specific) -To learner’s own past performance (self-specific)	Criteria-specific feedback for work itself Norm-specific feedback for student’s process or effort Self-specific feedback for illustrating growth and progress towards task
Valence	-Positive -Negative	Use positive comments that describe what actions were well done Give examples for improvement with negative comments
Specificity	-Excessive -Balanced -Vague	Be specific as possible, yet avoid nitpicking Provide specific feedback but do not complete the task for them Be direct: do not beat around the bush
Tone	-Implications -What students “hear”	Brainstorm what you will say and how you want the feedback to be received Choose words that communicate respect for the student and their work

Adapted from:   Brookhart SM. How to Give Effective Feedback to Your Students.  Alexandra, VA: Association for Supervision and Curriculum Development (ASCD); 2008.

How effective is feedback?

A comprehensive meta-analysis by Hattie in 2007 evaluated the effect of providing feedback in the classroom.²  This analysis examined factors that influence educational achievement such as schooling, homes, students, teachers, and curricula.  A subgroup analysis of studies evaluating feedback observed an average effect 50% greater than the effect than schooling itself.  Other influences on achievement in decreasing order of their magnitude of effect include direct instruction, reciprocal teaching, homework, the use of calculators, and reducing class size.  Most teachers are comfortable with providing homework and calculators, yet feedback is at least 50% more powerful at influencing the learners’ achievement.   Not all modes of providing feedback are effective.  Praise, punishment, and rewards contributed to the smallest effect on achievement.

A study evaluating survey responses of over 340 pharmacy students in the United Kingdom on their perceptions of feedback from faculty showed that 98% of students agreed that receiving feedback was an important part of their degree program and 80% of students agreed that feedback from faculty improved their performance.³  Not surprisingly, less than 33% of the students agreed that they were satisfied with the feedback they received.  Inconsistencies in providing feedback, the quantity, quality, and timing were common reasons cited by students.  Feedback given at the end of a module was viewed as the least useful.

Balance between positive and negative feedback

“Negative feedback isn’t always bad and positive feedback isn’t always good.  Too often, they say, we forget the purpose of feedback.  It’s not to make people feel better, it’s to help them do better”

- A. Tugent, New York Times

Studies have shown that learners that truly desire to improve their skills want constructive feedback and view the comments as opportunities for improvement and growth.  People learning a new task prefer positive reinforcement to boost their confidence.⁴   Yet some instructors struggle to give what some would perceive as “negative” feedback.  The term “constructive feedback” is perhaps better nomenclature.  Constructive feedback includes remarks that are productive, useful, redirecting, and motivational, not destructive.  This does not mean the learner should only receive praise.

Example of feedback techniques & Strategies ^(4-6)

One common method of providing feedback is the Feedback Sandwich.⁴  This technique provides the so-called negative feedback between two positive comments.  This strategy has received much criticism for being ineffective because many learners will only hear the praise, thus undermining the intent.  Authors of The Power of Feedback argue that focusing the feedback on the task and self-regulation are the most powerful modes of feedback, whereas feedback about the self as a person is the least effective. ²    In the One Minute Preceptor technique, the preceptor probes the learner for supporting evidence after the learner has articulated a recommendation.  The preceptor then reinforces actions done well and lastly makes recommendations for improvement.⁵   Another common way of providing feedback is the W3 in which the preceptor allows the learner to self-reflect utilizing three questions:  what worked well, what did not work well, what we can do differently next time.  There are other strategies such as 360 degrees that attempts to elicit feedback from various sources such as other learners, colleagues, as well as supervisors.

I like the W3 method but sometimes learners are their own worst critic; therefore, I like utilizing the W3 informally. I like constructive feedback from the instructor about a specific task in real time (e.g. while I’m performing the task or immediately afterward).  As a learner, the worst experience is not receiving any feedback until the end of the learning experience and realizing you weren’t meeting expectations.  It is human nature to assume if there is no feedback that everything must be fine.  At the very least, feedback sessions should be held formally at the middle and end … but informal feedback should be given as much as possible.

Effective feedback is essential for the learner’s growth and professional develop.  With practice, the instructor will develop his/her own strategy to effectively deliver motivational and useful feedback to learners of all levels.  Effective feedback is FAST:  frequent, accurate, specific, and timely.   If you are going to make a feedback sandwich, make it a “meaty” one.

References:

1. Brookhart SM. How to Give Effective Feedback to Your Students.  Alexandra, VA: Association for Supervision and Curriculum Development (ASCD); 2008. [cited March 5 20014]
2. Hattie J, Timperley H. The power of feedback.  Review of Educational Research. 2007:77-81.
3. Hall M, Hanna L, Quinn S. Pharmacy students’ views of faculty feedback on academic performance.  Am J Pharm Educ. 2012; 76: Article 5.
4. Tugend A. You’ve been doing a fantastic job. Just one thing... New York Times [online]. April 2013.
5. Hohrenwend, A.  Serving up the feedback sandwich.  Fam Pract Manag. 2002;9:43-6.
6. Furney SL, Orsini AN, Oretti KE, et. al.  Teaching the one-minute preceptor.  J Gen Inten Med. 2001;16:620-4.

Interprofessional Education: Just Another Catch Phrase?

by Allison Butts, Pharm.D., PGY1 Pharmacy Practice Resident, The Johns Hopkins Hospital

Only nine months into my pharmacy career and I’m tested every day to effectively use my clinical knowledge, rational decision-making skills, adaptability, and confidence to deliver optimal patient care working alongside health professional colleagues.  I found the transition from student pharmacist to licensed pharmacist to be fairly smooth, which I attribute to the interprofessional education I received in pharmacy school.  If healthcare practitioners are expected to work together, communicate, and use their skills in an integrated manner, it seems clear that it is best to train students in an interprofessional environment.  In writing this essay I reflected on my educational experiences and how best to prepare students for practice in healthcare today.

In 2003, the Institute of Medicine (IOM) issued a report entitled, “Health Professions Education:  A Bridge to Quality.”  This report highlighted a number of necessary changes to professional health care education to improve the quality of care provided in the United States.  The report emphasized five core competencies that should be addressed through professional education:  patient-centered care, evidence-based practice, quality improvement, informatics, and interprofessional teams.¹   The Accreditation Council for Pharmacy Education (ACPE) addressed the 2003 IOM reports and adopted the core competencies into their 2007 Guidelines for ACPE Accreditation Standards, with a special focus on interprofessional education.²  In 2011, a joint effort between the American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and the Association of Schools of Public Health further refined the core competencies.³  A 2012 survey found that only 34% of the participating colleges of pharmacy provided instruction regarding interprofessional teaming.  Most of these colleges / schools of pharmacy has some interprofessional teaching in their curriculum (53%), while others offered it as topic within a course (24%) or as a standalone course (17%) format.  While only a third were actively teaching interprofessional teaming, an impressive 83% of respondents indicated a desire to include this core competency into their curriculum.⁴

Colleges of pharmacy from across the country continue to look for new ways to teach the principles of interprofessional teaming in their curriculum.  Faculty from the South Carolina College of Pharmacy, MUSC Campus, recently published data on pharmacy students’ perceptions regarding interprofessional collaboration after completing a required longitudinal clinical assessment course.  The course addressed several domains of interprofessional education in nine separate learning activities.  The activities involved students from pharmacy, physician assistant studies, medicine, and nursing.  The Interprofessional Education Perception Scale (IEPS) was used to assess the perceptions of pharmacy students prior to and at the completion of the course.  In 16 of the 18 questions surveyed, perceptions of interprofessional collaboration improved after completing the course.  The items that had the most improvement were:  “individuals in other professions respect pharmacists” and “individuals in my profession are positive about their goals and objectives.”⁵

Other published examples of interprofessional teaching models include a required introductory pharmacy practice experience (IPPE) course in which pharmacy students visit practice sites of local physicians and nurse practitioners who serve as primary preceptors, participation in a service-learning advanced pharmacy practice experience (APPE), medical missions trips, patient simulation activities, and interprofessional didactic coursework.^6-12

Looking back on my pharmacy education, I recognize how fortunate I was to have trained at an institution located within a large academic medical center, especially one in which clinical pharmacy services are full integrated in the delivery of care.  When considering my personal experiences and reconciling them with examples from the literature, there is a combination of approaches that I believe will create the optimal environment for students to learn about the principles of interprofessional teaming and become skillful team members:

• Provide interprofessional experiences early and often.  It is never too early in the curriculum to introduce students to their health care colleagues.  Students across disciplines take many of the same basic science classes early in their respective programs, so should be feasible to have students from different professional programs in the classroom together.  Activities should evolve as students move through their curricula, allowing for the development of solid relationships prior to clinical rotations.
• Engage students in the development of interprofessional initiatives.  Students themselves can be the best gauges of a program’s success.  By understanding their needs, goals, and perceptions, educators can tweak the curriculum to best prepare students for clinical practice.
• Develop unique methods of student assessment.  Students are often graded at the completion of a interprofessional patient care activity (real or simulated) based on a SOAP note or patient presentation.  Educators should also measure the success of the team by how well they utilize their colleagues.  Students should be asked what each team member contributed as well as how they utilized their teammates to accomplish their tasks.
• Provide variety.  Ideally, health care students should interact with students from several different professional programs.  There are admittedly resource limitations and logistical barriers, but colleges/schools of pharmacy should strive to work with at least two other professional degree programs.  Create a variety of learning activities and consider nontraditional experiences to achieve the competency standards. 

The concept of interprofessional education is more than a catch phrase in today’s professional education landscape.  It is a true necessity in preparing pharmacy and other health professional students to become successful practitioners.  Primary professional education organizations have formed a united voice in favor of this practice model and interprofessional training should be a priority at schools/colleges across the country.

References

1. Greiner AC, Knebel E, eds.  Institute of Medicine.  Health Professions Education:  A Bridge to Quality.  Washington, DC:  National Academies Press; 2003. Accessed 10 March 2014. 
2. Accreditation Council for Pharmacy Education.  Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree.  Guidelines Version 2.0 for Standards 2007.  Effective February 14, 2011.  Accessed 10 March 2014. 
3. Interprofessional Education Collaborative Expert Panel.  Core Competencies for Interprofessional Collaborative Practice:  Report of an Expert Panel.  Washington, DC: Interprofessional Education Collaborative; 2011.
4. Zeind CS, Blagg JD, Amato MG, and Jacobson S.  Incorporation of Institute of Medicine Competency Recommendations within Doctor of Pharmacy Curricula.  Am J Pharm Educ.  2012; 76: Article 83.
5. Shrader S, Griggs C.  Multiple Interprofessional Education Activities Delivered Longitudinally Within a Required Clinical Assessment Course.  Am J Pharm Educ.  2014; 78: Article 14.
6. Turner CJ, Altiere R, Clark L, Dwinnell B, and Barton A.  An Interprofessional Introductory Pharmacy Practice Experience Course.  Am J Pharm Educ. 2004; 68: Article 10.
7. Jones KM, Blumenthal DK, Burke JM, et al.  Interprofessional Education in Introductory Pharmacy Practice Experiences at US Colleges and Schools of Pharmacy.  Am J Pharm Educ.  2012; 76: Article 80.
8. Johnson JF.  A Diabetes Camp as the Service-Learning Capstone Experience in a Diabetes Concentration.  Am J Pharm Educ.  2007; 71: Article 119.
9. Werremeyer AB, Skoy ET.  A Medical Mission to Guatemala as an Advanced Pharmacy Practice Experience.  Am J Pharm Educ.  2012; 76:  Article 156.
10. Fernandez R, Parker D, Kalus JS, Miller D, Compton S.  Using a Human Patient Simulation Mannequin to Teach Interprofessional Team Skills to Pharmacy Students.  Am J Pharm Educ.  2007; 71: Article 51.
11. Van Winkle LJ, Cornell S, Fjortoft N, et al.  Critical Thinking and Reflection Exercises in a Biochemistry Course to Improve Prospective Health Professions Students’ Attitudes toward Physician-Pharmacist Collaboration.  Am J Pharm Educ.  2013; 77: Article 169.
12. Westberg SM, Adams J, Thiede K, Stratton TP, Bumgardner MA.  An Interprofessional Activity Using Standardized Patients.  Am J Pharm Educ.  2006; 70: Article 34.