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.