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.

Developing Residents into Preceptors Using the Layered Learning Practice Model

by Brianna F. Waller, PharmD, PGY-1 Pharmacy Practice Resident, Baptist Memorial Hospital – North Mississippi

During their year-long commitment toward becoming a competent practitioner, many pharmacy residents (and other post-graduate trainees) will suddenly find themselves partially or fully responsible for someone else’s learning as a “preceptor." Although assuming this role may make some residents uneasy, the positive benefits of “near-peer” teachers and layered learning have been repeatedly discussed in secondary and higher education literature. Indeed, medical school students report they value and respond well to learning from near-peers due to their recent experience and relatability.  Near-peer teachers are not too far removed from the students’ “struggles” and experiences.¹ Let’s take a closer look at how this can be applied within pharmacy education.

Layered-Learning Practice Model
Senior educators work with advanced learners to teach junior leaners

A survey sent to all residency program directors (RPDs) of ASHP-accredited programs determined precepting opportunities for residents, identified barriers to developing precepting skills, and discovered opportunities to optimize programming. Among the 538 responses, the researcher found that 71% of residency programs did not offer a formal precepting rotation despite the fact that 59% of RPDs admitted their graduates frequently accepted positions that involved teaching / precepting.² Just as importantly, there is a serious shortage of pharmacy preceptors!  In another survey (n= 4,396) of pharmacists, 73% accepted an invitation to precept two or more students in the past year but almost half turned students away.³ This gap is a glaring opportunity for the layered learning practice model.  One of the benefits of this model is the fact that it increases the amount of time that attending pharmacists (aka senior preceptors) can spend focusing on their practice while allowing the resident to spend the most time supervising students and thereby gaining valuable precepting experience. Engaging residents in this role increases the number of people available to precept the growing number of student pharmacists without causing the workflow to suffer. Providing structured experiences for residents to precept students not only helps fill the gap, but they get feedback about their precepting skills before accepting post-residency positions that require them to teaching/precepting.

The layered learning practice model (LLPM) is a teaching strategy designed to train residents to precept students and, in some cases, more junior residents with oversight from a more experienced pharmacist. The four recommended steps to help all parties get the most out of the LLPM are orientation, pre-experience planning, implementation, and post-experience evaluation.⁴ I will use my own experiences with the Teaching & Learning Program during my PGY-1 program through the University of Mississippi School of Pharmacy (UMSOP) to illustrate concepts of the LLPM.

Let’s start by breaking down each component of the LLPM. Orientation to the LLPM is vital not only for the resident but also for the attending pharmacist. This helps outline goals, expectations, and responsibilities for each party, thus reducing the potential for overlap and confusion.⁴ In my own experience, this was extremely beneficial given the chaotic effect that COVID-19 seemed to have on nearly everything at the School of Pharmacy and the Medical Center. I had several meetings with faculty and staff regarding my role, a list of things I needed to accomplish, and, most importantly, how to use the tools to host virtual seminar meetings and IPPE rotation experiences. Typically, during the orientation the resident gets some feedback regarding his/her performance which can help build their confidence and independence.

Table 1: Typical Roles and Responsibilities in the LLPM

Primary Preceptor	Orient resident & student to layered learning practice model, practice site, and staff Create or obtain resident and student syllabus Outline trainee responsibilities Define the expectations of all learners Assist resident performance for clinical and teaching activities Evaluate resident performance for clinical and teaching activities Oversee all patient care activities and pharmacy education
Resident Preceptor	Discuss learning experience with preceptor prior to the first day Assist in the development of student calendar and rotation activities Orient student to practice site and establish goals Integrate student into patient care activities Supervise student during patient care activities Obtain any resources students need to perform required activities Provide regular feedback to students Lead topic discussions and other educational activities Evaluate the performance of the student and provide regular feedback
Student Learner	Report directly to the resident preceptor Actively participate in patient care and rotation activities Provide feedback on the layered learning practice model and resident performance as an experiential educator

Once everyone's roles (see Table 1) are established, pre-experience planning begins. The resident is involved by developing activities and materials for students to uses. Examples include developing calendars, rubrics, and activity descriptions.⁴ For me, I develop presentations and getting a once-in-a-lifetime opportunity to create a 4-hour IPPE experience on chart review & labs.  Because students were no longer allowed at our practice site due to the risk of COVID-19 exposure, I had to deliver this instruction using a videoconference tool. The LLPM process allowed enough structure for me to develop these activities independently, while also having the support of my preceptor when needed.

The implementation stage is relatively self-explanatory. The material prepared by the resident is delivered. The resident is considered the primary preceptor for the student(s), and depending on the activity, they are responsible for assigning them specific patient care duties, evaluating student performance, or providing feedback. The senior preceptor continues to be available and provides guidance to the resident. In longitudinal settings, such as precepting over the course of the month, the preceptor directly observes the resident periodically in order to assess progression.⁴ In situations such as delivering a presentation, it is important that the senior preceptor observe the session in order to provide constructive feedback to the resident, as was done in my case.

Finally, post-experience evaluation occurs whereby the primary preceptor solicits and provides feedback to resident(s) and student(s).⁴ An additional benefit is the identification of potential improvements that can be made within the LLPM at the institution, as well as the opportunity to solicit feedback from both layers of learners regarding their experiences and suggestions for improvement. One of the most helpful ways this was achieved in my own experience was by surveying the students in an effort to measure the effectiveness of my presentation, as well as obtain recommendations for improvement.  Afterward, I discussed this feedback in great detail with my preceptor.

More residency programs should adopt the layered learning practice model, as it appears to not only address the need for more preceptors but also affords the resident meaningful teaching experiences, and provides a more relatable role model for students. 

References

1. Lockspeiser T, O’Sullivan P, Teherani A, and Muller J. Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Health Sci Educ 2006;13(3):361-372.
2. Dipaula BA, Mohammad RA, Ayers P, et al. Residents as preceptors and educators: What we can learn from a national survey to improve our residency programs. Curr Pharm Teach Learn 2018;10(1):21–7.
3. Skrabal MZ, Jones RM, Nemire RE, et al. National Survey of Volunteer Pharmacy Preceptors. Am J Pharm Educ 2008;72(5): Article 112.
4. Loy BM, Yang S, Moss JM et al. Application of the Layered Learning Practice Model in an Academic Medical Center. Hospital Pharm 2017; 52 (4): 266-272.