Listen, Clarify, and Appreciate! Best Practices When Receiving Feedback

by Camron Jones, PharmD, PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

 “It takes humility to seek feedback. It takes wisdom to understand it, analyze it and appropriately act on it”
-Stephen Covey.¹

What do you feel when you hear the word feedback? Do you feel nervous?  Perhaps scared about what the person might say? Do you clam up thinking you have done something wrong? I have a love/hate relationship with feedback. I love knowing how I am performing.  But I sometimes fixate on the things I did “wrong.” It can be intimidating and sometimes we get stressed out about the small things. For many people, it’s hard to accept feedback because it’s perceived as a negative judgment. I have grown to appreciate feedback because it helps me understand what I am doing well and what I need to work on. I think it’s intimidating to ask for feedback. This is something that I am working on. Not only is feedback hard to ask for, but it’s hard to give.

Feedback is the act of someone providing information about a person’s performance of a task and the recipient using the information as a basis for improvement.² Frequently we talk about how to formulate feedback so that we can help another person excel. But receiving feedback is a critical skill too. All of us need to learn to receive feedback graciously and not jump to conclusions. Both giving and receiving feedback are difficult! If we use the right techniques, we can learn as well as teach others. Let’s take a deep dive into receiving feedback by examining the best practices and how to teach it.

There are three crucial steps that should be adhered to if we want to maximize the benefits of receiving feedback. These include actively listening, clarifying the feedback, and expressing gratitude.^3,4  Listening with an open mind is a huge part of the feedback process. Listening promotes our personal and professional growth. Too quickly we jump the gun and interrupt the person providing the feedback. In the Christian Bible, there is a saying that resonates with that I believe applies to receiving feedback: “..let every man be swift to hear, slow to speak.” When receiving feedback, we must consider all of it before responding. Reflecting on the feedback is so important because it helps us grow.

When you hear words that you interpret as negative it can bring you down. But it’s important to ask questions because without getting clarification, you can create an injustice and take feedback too personally. The feedback is about your performance, not about you as a person. I feel like this is critical to understanding how to receive feedback. The person giving the feedback is only trying to help us succeed and grow.  If we dismiss or reject the feedback, we are disadvantaging ourselves.  So, ask clarifying questions!  Make certain you fully understand what the person giving the feedback is telling you. Ask for specific examples.

Finally, it’s important to express appreciation to the person providing the feedback. Remember, the person giving the feedback is usually uncomfortable.  Giving feedback and telling someone something they might perceive as negative can be intimidating. It's easier just to not say anything.  Or to tell someone everything is perfect. But the person giving feedback took the time to carefully consider how to help you improve and they want you to succeed! If we show appreciation, they will feel encouraged and more willing to share with us. 

Tips for Receiving Feedback:3

Be a good listener When in doubt, ask for clarification Embrace the feedback session as a learning opportunity Remember to pause and think before responding Avoid jumping to conclusions, and show that you are invested in the learning process and keen to improve Think positively and be open to helpful hints Learn from your mistakes and be motivated Be a good sport and show appreciation Be proactive – ask for feedback!

Studies have repeatedly shown that effective feedback has a powerful influence on how people learn. In one study involving medical students, they looked at methods to teach how to use feedback. They developed a 2-hr workshop that focused on writing goals in a learning contract, defining effective characteristics of feedback and practicing the use of feedback in response to feedback received. Following the workshop, student group scores increased significantly. They also looked at how coaching improved students' perception of their feedback skills. They noted how students' feedback interactions improved, especially during informal interactions. In a model that defines the communication pathway, they described how the process of feedback could falter. This could be due to previous experiences from the receiver, also the fear of damaging relationships between the giver and receiver.⁴

Another study enrolled second and third-year internal medicine residents. This study focused on a One-Minute Preceptor model. This was a conversation between the resident and the teacher to help improve the resident's clinical skills. One of the greatest benefits of the One-Minute Preceptor model is feedback. At baseline, feedback was ranked as one of the weaker areas. Significant improvements were reported at the end of the study. Feedback was shown to have the greatest impact on performance.⁵ 

Another good resource is the ask-tell-ask feedback model.⁶ For example, say you are a student, and you provided education to a patient about anticoagulation therapy. With the first ask, the preceptor asks the student to talk about how they thought the experience went. The preceptor then gives feedback on what was observed, both positive and negative aspects of the performance.  This is the tell component of the model. During the last ask, the student then reflects on what the preceptor has told them and they both set goals moving forward.⁶ This allows the receiver to actively participate in the conversation and formulate an action plan. I personally experienced this method of feedback in my last year of pharmacy school. Not only did it help me improve, but it also helped me be more open to feedback.

As teachers, we must learn to give feedback in a way that positively affects our students. We should allow students time to self-reflect before giving feedback. This gives the students an opportunity to think about the strengths and weaknesses of their performance. As a learner, we must learn from the feedback and use it as a tool for us to improve. Be sure to listen, clarify, and appreciate!

References

1. Covey, SR. Stephen R. Covey interactive reader-4 books in 1: The 7 habits of highly effective people, first things first, and the best of the most renowned leadership teacher of our time (Internet). Mango Media. 2015 (Cited 2021Oct1)
2. “Feedback”. Merriam-webster.com dictionary, merriam-webster. www.merriam-webster.com/dictonary/feedback. (Cited 2021Sept29).
3. Hardavella G, Aamil-Gaagnat A, Saad N, et. al. How to give and receive feedback effectively. Breathe 2017; 13:327-333. 
4. Bing-You RG, Bertsch T, Thompson JA. Coaching medical students in receiving effective feedback. Teaching and Learning in Medicine 1998; 10(4):228-231. 
5. Furney SL, Orsini AN, Orsetti KE, et al. Teaching the one-minute preceptor. J Gen Intern Med. 2001;16:620-624.
6. Jug R, Jiang X, Bean S. Giving and receiving effective feedback: a review article and how to guide. Arch Pathol Lab Med 2019; 143 (2):244-250.

The Flipped Classroom Model in the Age of Virtual Learning

by Emily Plauche, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Virtual learning played a huge role in higher education during the COVID-19 pandemic. In March 2020 when the pandemic first began to spread in the United States, educators had little time to transition to an online learning environment. Some schools gave students a few weeks off to allow time for administrators and teachers to make plans and learn how to use the technology while others immediately transitioned to an online platform with little guidance. Virtual teaching can be done synchronously via platforms such as Zoom and asynchronously using pre-recorded lectures or other online resources. Live classes allow for more interactive learning but may be limited by technical difficulties and students’ access to technology. Pre-recorded lectures provide students with more flexibility in terms of how and when they prefer to study, but students may feel disconnected from their classmates and instructors.¹  In order to best recreate the flipped classroom model, asynchronous pre-class assignments with synchronous/ live in-class activities would be ideal. Now that the education system has had more time to adapt and is able to provide almost all features of an in-person classroom experience in a virtual platform, it raises the question of whether the flipped classroom model is still effective in a virtual learning setting.  Giving students the option to attend class in person or online may become common practice as the COVID-19 pandemic persists, technology advances, and our comfort with virtual learning grows. 

The flipped classroom model is a somewhat new teaching strategy that focuses on in-class application, rather than lecturing. Instead of homework after class, students complete pre-class assignments in order to prepare for class and class time is reserved for discussions, case studies, and other activities that require students to apply what they learned prior to class. The flipped class has become increasingly popular over the last decade. A meta-analysis studying the flipped classroom model in health professions education found that the model provided several benefits including a statistically significant improvement in learner performance compared with traditional teaching methods, more time for active learning during class time, and the opportunity for students to study at their own pace before class. The analysis also found that more students favored this method of learning over traditional lecturing. However, this model requires students to prepare ahead of time in order for the activities in class to be productive. The increased burden on the student can be a limitation to its success and should be considered when teachers assign out-of-class activities.²

Traditionally, pre-class assignments are done remotely via pre-recorded lectures and required readings, and the interactive classroom activity is done in person. However, COVID-19 required all learning activities to be done virtually. Educators wanting to implement this model while teaching virtually should provide both pre-recorded lectures and live but virtual classes in order to effectively mimic the model. The question is whether a flipped classroom model is still effective in an online learning environment. A study performed in Spain specifically compared performance and emotions towards the flipped classroom model in undergraduate STEM courses before and after the COVID-19 pandemic comparing two groups: “face to face” and “face to screen.” The course consisted of three hours of live class with pre-recorded lessons to watch in preparation for class in both groups. The instruction methodologies, syllabi, and structure were identical in both groups. The study did not disclose what type of assessments were used but the “pass rate” was similar in the two groups with 67.1% of students in the face-to-face group achieving a “passing” score compared with 70.3% in the face-to-screen group.  The difference was not statistically significant. Face-to-face instruction was associated with more positive emotions such as enthusiasm, confidence, tranquility, and fun while face-to-screen instruction was associated with more negative emotions including concern, nervousness, fear, and boredom.³

Some of these negative emotions observed in the face-to-screen group were likely influenced by the uncertainties at the beginning of the pandemic and were not solely due to virtual learning. As students become more acquainted with distant learning, it is likely the virtual classroom will be perceived less negatively. However, student engagement and attention in the virtual classroom may be persistent challenges. It is promising that there was not a statistically significant difference in performance between the groups, suggesting that the flipped classroom is an acceptable approach to teaching in a virtual setting.

Instructors can work to increase virtual student engagement by offering a variety of ways for students to participate. Some may prefer to use the microphone, type in a chat box, or use the raise hand feature. By offering multiple options, students are able to interact in a way that they feel most comfortable. Breakout rooms can also be used to facilitate work in small groups, which might reduce students' anxiety about taking in front of a large group. Teachers can also ask their students for feedback throughout the semester to better understand students’ needs and concerns. To minimize technical difficulties, teachers should perform test runs before live class sessions to ensure Zoom links, internet connection, and sound are working properly.

The flipped classroom model allows for more interactive classroom experiences between students and teachers and has been shown to improve student performance when compared to more traditional methods to teach. While we have limited data from studies, the flipped classroom method still works in a virtual classroom setting. Teachers planning to utilize the flipped classroom model in an online class may face challenges including technical difficulties along with reduced student engagement, attention, and attitude towards virtual learning. Teachers should keep this in mind as they develop material to teach virtually. As more research is published about online teaching methods, educators will have a better understanding of how to approach teaching in virtual classrooms.

References:

1. Camargo CP, Tempski PZ, Busnardo FF, Martins M de A, Gemperli R. Online learning and COVID-19: a meta-synthesis analysis. Clinics 2020;75: e2286.
2. Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ. 2018;18(1):38.
3. Jeong JS, González-Gómez D. A STEM Course Analysis During COVID-19: A Comparison Study in Performance and Affective Domain of PSTs Between F2F and F2S Flipped Classroom. Front Psychol. 2021;12:669855.

Get Down with the Feeling: Teacher Empathy

by Taylor Adcock, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Empathy involves understanding another person’s experiences by imagining oneself in the other person’s situation.¹ We live in an increasingly diverse society today and empathy improves social cohesiveness.  For this reason, empathy is particularly important in classrooms and influences how teachers and students interact. Studies have shown that cognitive and emotional empathy can promote students’ learning as well as help teachers have a more positive mindset and avoid burnout.^2,3,4 Teacher empathy is not a widely talked about subject. This article will look at how teacher empathy can help promote student learning and success.

The term empathy originates from a German word that means "feeling into.” There are two forms of empathy: emotional and cognitive. Most people conceptualize empathy as emotional empathy whereby the individual feels the same emotion as another person.  When a person has personal distress, emotional empathy enables us to feel compassion or empathic concern. Empathic concern is typically developed later in life as it builds off and requires more self-control. Empathic concern also triggers prosocial and helping behaviors.  Emotional empathy is positively correlated with a willingness to help people even if it requires personal sacrifices.¹ Intense emotional empathy is often called empathic accuracy. Empathic accuracy allows a person to have more accurate and complete knowledge about what is going on in a person’s mind and how they feel.

Cognitive empathy is the extent to which we perceive or presuming another person's thoughts and feelings.  This can involve an understanding of what someone might be thinking during tasks – from simple tasks to more complex ones. Simple tasks can include visually perceiving standing in a classroom teaching and imagining what another person walking by the classroom might see (observe). Complex tasks can include thinking about what a group might perceive or think. Cognitive empathy still requires sensitivity and knowledge of what other people are thinking and feeling but does not necessarily mean that a person cares about the other person.  This means cognitive empathy can be used to harm others. Con artists, for example, have well-developed cognitive empathy in that they understand what others are likely thinking and feeling but they don’t care about the welfare of the person they are taking advantage of. Cognitive empathy is part of our mental development because we grow to understand that another person's thoughts differ from our own.¹ 

Studies that have looked at teacher empathy toward students have found that it can have a positive influence on both students and teachers. One study looked at empathetic climates in the classroom and measured student success.² Empathetic climates are created when the teacher pays attention to student opinions, values what students have to say, and when students believe the teacher “understands our frame of references”. The study enrolled nearly 500 middle and high-school students. Results from this study showed that an empathetic climate was positively correlated with students’ success even if a class was deemed particularly hard. Success was defined by students ranking their performance in the course using a 6-point Likert scale. The students succeeded, even in difficult classes, if they felt unconditional regard from the teacher.

Another study followed 178 elementary school teachers and looked at the benefits teachers received based on their level of cognitive empathy. Results showed that higher levels of cognitive empathy were associated with lower job burnout, positive mindsets about student behavior, better relationship closeness, and better competence in handling students’ problem behaviors. On the other hand, teachers who experienced high empathetic distress, such as becoming overwhelmed by the student’s emotional experiences, showed that there was higher job burnout, less competence with students’ problem behavior, negative mindsets with misbehavior, and fewer problem-solving strategies.³

There are 4 ways that teachers (you) can create a more empathic climate:⁴

1. Perspective-taking –this means putting aside your perspective and looking at the situation from a different angle. Consider asking, “Do I believe my students are doing the very best they can?”  Every student is not going to have the same skill set when it comes to learning which means they may be trying their best already. Encouraging them through a challenging subject is important.
2. Putting aside judgment – this means to step back and not jump to conclusions solely based on what is seen. Consider asking, “What more do I need to learn and understand about the situation?”  For example, if you have a student who is struggling with assignments and submitting them on time, do not assume that they are lazy. Come in at a different angle and make sure that home life is okay first.
3. Trying to understand the student’s feelings – tap into your own experiences to try to find a way to understand what the student is going through or to remember when you went through a similar experience; however, remember that everyone does not feel the same things, and we each have unique experiences. Consider asking, “What more do I need to learn and understand about how other people are reacting to or perceiving the situation?” If a student loses a family member, it is important to try and understand how you felt at this time and then give leniency as the student may or may not have difficulty coping.
4. Communicate that you understand – talk to students with reflective phrases such as “It sounds like you…” or “I hear that you…”; this can help build trust and can help students to solve problems, with you in the beginning and eventually on their own. This step requires self-reflection so consider asking, “What more do I need to learn and understand about how I react?” and “What more do I need to learn about how to communicate to others that I hear them, even while experiencing my own emotions?” For example, if a student has many tests one week and is late on assignments, reaching out and say “It sounds like this week may have been overwhelming for you.”

Empathy is understanding what others are feeling and thinking and is associated with helping behaviors even it involves some personal sacrifice. Empathy also involves an understanding that we do not all think in the same manner. Teachers who cultivate an empathetic climate can achieve positive outcomes not only for the student but also for themselves.

References:

1. Hodges SD, Myers MW. Empathy. 2007 (Accessed 2021 Sept 11).
2. Bozkurt T, Ozden MS. The relationship between empathetic classroom climate and students’ success. Procedia - Social and Behavioral Sciences. 2010;5:231–4.
3. Wink MN, LaRusso MD, Smith RL. Teacher empathy and students with problem behaviors: Examining teachers’ perceptions, responses, relationships, and burnout. Psychology in the Schools. 2021;58(8):1575–96.
4. Morin A. Teaching With Empathy: Why It’s Important. Understood.org [Internet]. (Accessed 2021 Sep 11).