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.