Giving and Receiving Feedback Combining results from two qualitative studies

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Giving and Receiving FeedbackCombining results
from two qualitative studies

• Dr Elizabeth Molloy
• Dr Clare Delany
• Department of Physiotherapy
• Monash University

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Active participation practising what we preach

• Scenario 3rd year student
• James, the student, is a high achiever both
  academically and in the sporting field and has
  rarely received negative feedback. During his
  initial interviews with patients, James has
  demonstrated a lack of responsiveness to the
  patients comments and instead appears focused on
  adhering to a script of questions. Yesterday,
  during the physical assessment of a patient, he
  failed to perform a neurological examination
  despite the patients report of pins and needles
  and numbness. The educator notices that James is
  defensive when he is provided with informal
  feedback after working with patients. He debated
  most of the points raised and commented that I
  am doing these things, its just that youre not
  seeing them.
• 1) How will you improve this students
  learning/performance?
• 2) What feedback will you provide to this
  student? How ?

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In todays talk

• Introduce the concept of feedback
• Identify key themes about feedback from 2
  separate studies
• Discuss barriers to using feedback within the
  clinical education process.
• Present models of practice and strategies to
  improve feedback in clinical education

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Feedback is

• Information on actual performance in relation to
  the intended goal of performance
• (Titchen 1995)

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Why is feedback important?
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What do we know about feedback?
What does the literature say about best
practice feedback?

• Valued highly by educators and students
• Feedback improves learning outcomes
• The literature on feedback does not match
  education literature
• didactic approach versus adult learning
• Limited empirical studies investigating the
  feedback process in health education (Ende 1983
  and Silverman et al 1996)
• Emphasis on Equals and Allies

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Study 1 Research Methodology (Molloy 2006)
Phase 1 Supervisor Questionnaire (n102 RR 88)
Phase 2 Observation and Interviews with students
and clinical educators at 3 and 6 weeks (18
videos, 36 interviews)
Phase 3 Interviews with key educators N2
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Research Methodology (Molloy 2006)
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Findings Clinical Educator support of advocated
principles in the literature

• Respondents were asked to rate the importance of
  factors contributing to an effective feedback
  session
• Two-way interaction featured highly
• Giver and receiver of feedback are positioned as
  equal in the exchange of information

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Positioning as Equals and Allies
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Clinical Educator support of advocated principles
in the literature

• This congruence between educator reports of
  effective practice and the literatures advocacy
  of best practice was reported in Neville and
  Frenchs (1991) study
• Many of the students and clinical tutors
  express views compatible with the literature on
  adult learning p. 353

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Phase 2

• Even if educators do value these principles
• 1. Are they applying them in practice?
• What we say we do can be different to what we do,
  without reflecting an intention to deceive (Kagan
  1988)
• 2. What are the barriers/opportunities for
  applying the theoretical ideals in practical
  clinical placement settings?

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Phase 2 Results

• Feedback a monologic culture
• Tokenism
• Adopting positions

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Feedback 1. A monologic culture

• I felt that perhaps I talked too much, maybe
  just should have given her a bit more openness to
  talk throughout the session. Like she gave me
  some good comments at the end, but perhaps just
  could have paused a bit for her responses a bit
  more Supervisor 1
• Sometimes I catch myself and think youve been
  talking for a long time now Supervisor 2

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Feedback A monologic culture

• One-way feedback exchange
• Minimal student self-evaluation
• Minimal student preparation for the sessions
• Almost no collaborative development of strategies
  for improvement

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2. Tokenism

• In 16/18 videotaped sessions, educators opened
  the discussion with an invitation for student
  self-analysis
• Clinical educator How do you think you went?
• Student Yeah I definitely felt like Ive
  improved
• Clinical educator Theres been a big difference
  from the first half to the second half. So
  starting with your subjective assessment..

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Tokenism

• Clinical Educator Weve all got time restraints
  so you know, saying what did you do well? and
  then giving feedback, it all takes extra time an
  thats an issue as well. And you know, I find
  myself saying to the student Ok, what did you
  think? and then hoping inside me that theyll be
  really quick about what they want to tell me

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Tokenism

• Are clinical educators expecting in depth
  self-analysis or are these examples of playing
  the game or tokenism?
• What are the barriers to enactment of the ideals
  of feedback?
• Do students and clinical educators actively
  conspire to generate a one-way feedback culture?
• What are the influences and what are the
  incentives to enact this model?

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Adopting positions

• Clinician as a diagnostician
• Student as a passive accomplice

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Clinical educator positioned as diagnostician

• Positioning Theory lens to sharpen the focus of
  the discourse analysis
• Harre (1999)
• Origins in discursive psychology (Vygotsky 1986)
  

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Adopting Positions

• Positioning theory provides a lens through which
  to observe
• Social hierarchies/relationships implicit in
  conversation
• Power, assigned responsibilities and identity
  construction in conversational encounters
• Positions are adopted or assigned
• Positions can be accepted or contested
• Pronoun analysis index the social or moral
  standing of the speaker

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Adopting Positions

• Research data
• students positioned clinical educators as
  diagnosticians, and clinical educators
  positioned themselves in this way.
• Minimal student voice in the sessions
• Shared expectation/complicity
• Path of least resistance for both parties
  (clinician clinical transference, student
  saving face)

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Clinical educator positioned as diagnostician

• Interviewer I suppose that is a different model,
  that self-evaluation model, compared to the
  student doing their stuff and the supervisor
  coming in and being the diagnoser of
  performance?
• Clinical educator Yes, I think that definitely
  goes on here, no doubt. I think theres a lot of
  that that goes on because its the physio way.

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(No Transcript)
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Clinical educator positioned as diagnostician

• Clinical educator We dont do a lot of that
  self-evaluation is the short answer. And the
  reason is that a lot of the time we found that
  students arent comfortable with that. So because
  theyre not comfortable with that, and its a lot
  quicker getting through it this way, we dont do
  it

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Barriers identified by research

• Educators
• Clinical educators may be limited in time
• (balancing patient load and student load)
• Clinical educators may not be skilled in
  facilitating students self-evaluation
• Clinicians adhering to historical models of
  clinical education practice
• Clinicians tendency to diagnose and fix
  rather than collaborative decision making
  (transference from clinical paradigm)

• Students
• Students reticence to evaluate their own
  performance through fear of being wrong
• Students positioning of the educator as
  content/practice expert
• Students concern in challenging educators view
  due to reasons of power/hierarchy
• Student perfectionism and concern for assessment
  rather than learning

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Study 2 (Delany 2006)

• Students and educators experience of clinical
  education

• Research aims
• Examine both students and clinical educators
  experiences and perspectives of learning and
  teaching clinical skills within the third year
  physiotherapy undergraduate clinical placement
  program.
• 2. Introduce and evaluate the effects of a six
  week (three hours per week) critical reflection
  program

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Research Rationale

• 1. Economic
• Clinical education is resource intensive and
  expensive
• Demand exceeds supply
• 2. Changing professional roles
• Expectations include adaptability, critical
  thinking, broader scope of practice

Need for strategies and innovations in clinical
education
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Method Overall Research Framework
Austin Educator and Student focus groups
Clinical placement 1
Clinical placement 2
Clinical placement 3
RMH Educator and Student focus groups
Clinical placement 2 and critical reflection
program
Clinical placement 1
Clinical placement 3
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Methodology (Delany 2007)

• Qualitative approach
• Data collected via focus groups of students
• Context University of Melbourne, School of
  Physiotherapy
• Participants 3rd year physiotherapy students
• (3 six week placements of experiential learning)
• 5. Participants 3rd year physiotherapy student
  educators

• 45 Students (50 year level)
• 19 Educators
• 14 Participants in Critical Reflection Program

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Research Focus

• Educators experiences of teaching students
• 1. Which best describes how you ideally see your
  role as a clinical educator?
• Teacher
• supervisor
• Educator
• Mentor
• Assessor
• Role model
• 2. What are your expectations of students on a
  clinical placement?
• Performance
• Understanding
• Learning
• 3. What factors influence your teaching ideals

• Student experience of learning in their first
  clinical placement
• How would you describe your learning strategies
  in this clinic
• What influences your ability to learn
• What has been a critical incident in your
  learning in this clinic.

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How did students describe their learning
experiences?
Week 6
Internal focus
Resilience Confidence
Integrating knowledge Playing the game
External focus
Learning strategies Influences on learning
Knowledge And knowledge gaps
Week 1
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Student experience
Internal focus

• Learning strategies
• Influences on learning

Knowledge And knowledge gaps

• Need for adaptability
• The need to ask questions
• Tension between need for supervision and need for
  learning from treating
• Need to play the game

Students identified ways to adjust their own
learning
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Results students
Learning strategies Influences on learning

• Effective learning strategies identified by
  students
• Clinical educators who
• 1. Modelled good treatment and provided time for
  reflection
• Being given an opportunity to watch an entire
  assessment and treatment is a helpful strategy.
  There is a lot of pressure to always be doing and
  participating and leading yourself
• 2. Established student knowledge base prior to
  the patient encounter
• If someone said do this and youve never done it
  before and you try to fumble your way through it
  and then the supervisor jumps in when youre half
  way through, that style of teaching doesnt help
  anyone
• 3. Gave direct and immediate feedback
• If you get it feedback straight away then you
  know exactly what you need to do the next time
  rather than a week later saying You know you
  could have done this
• 4. Provided opportunities to learn with dignity

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Results Educators

• Educators overriding concerns were with
• Identifying
• Building
• Shaping
• Student knowledge

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External focus
Incremental building of knowledge
Filling knowledge gaps
Identifying Knowledge And knowledge gaps
Internal focus
Past Experience Teacher and student
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Educators

• External focus

• Identifying signs of student progress
• Correct order of problems
• Analysis
• Conceptual understanding
• Treatment effectiveness
• Time management
• Adaptability
• Think outside the square

WK 1
WK 6
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Results What do educators expect from students?

• (Implicit)
• see what we see
• A good student is able to ascertain basic
  information from the patient and then analyse it
  in the correct way and basically see what we see

• External focus

Signs of student progress Correct order of
problems Analysis Conceptual
understanding Treatment effectiveness
Time management
Adaptability Think outside
the square
WK 1
I am happy to admit that when I see a very good
student they usually have implicit features that
you just sense as an educator
WK 6
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Educators
External focus
They need to take responsibility for their own
learning

• A good student
• Takes responsibility
• Shows initiative
• Is professional
• Is confident

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Student/educator comparisons similarities
Week 6/18
Students recognise knowledge required and gaps in
their knowledge
Week 6/18
Students
Knowledge Theory to practice
Week 1
Educators recognise knowledge required and gaps
in their knowledge
Educators
Week 1
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Student/educator comparisons less similar
Students identify influences on their learning
and different learning strategies.
Students
Learning strategies
Educators are aware of different learning
strategies but focus more on skill acquisition
and filling gaps
Educators
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Student/educator comparisonsleast similar
Students recognise its significance and identify
strategies to achieve it
Student Confidence
Students
Educators recognise its significance and wait for
students to demonstrate it
Educators
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What can be learnt from this research?
Week 6/18

• Barriers identified
• Goals of clinical education are directed towards
  achieving competencies
• Educators rely on their past experience to inform
  their current teaching practices
• Educators focus on student deficits
• Educators are challenged by competing roles of
  clinician, manager and teacher

Students
Educators
Week 1
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Students and educators Differences

• 1.Educators focused on incremental building of
  technical skills as a way to build skill level
  and capacity and student confidence
• 2. Relied on past experience
• 3. Focused externally on core skills and
  competencies

• 1.Students looked for acknowledgement, inclusion
  and affirmation as ways to achieve success and
  build confidence
• 2. Students moved from an external focus to an
  internal focus (student learning -dynamic)

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In conclusion, both studies identified that

• 1. Feedback was an integral process to aid
  student learning
• 2. The way feedback was delivered affected
  students capacity to hear the message and act
  upon it
• 3. Students want access to good feedback but
  were both ill equipped and reluctant to
  participate.
• 4 Students need encouragement and leadership to
  contribute their views
• 5. Educators are aware of best-practice feedback
  principles but need support and explicit training
  to effect change

Educators
Students
Good feedback 2 way Collaborative Equal
positioning Timely
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Combining research Feedback Models
Molloy (2006)
Delany (2006)

• B BUILD esteem in students
• U UNDERSTAND students perspectives
• I INSIST on reflection within and about
  learning
• L LIST strategies for students to actively
  learn new skills
• D DECIDE on actions together to promote
  students clinical skill learning

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Combining research Strategies for achieving
models of effective practice

• Feedback built into curriculum structure early in
  academic environment (weekly group feedback in
  CBL, 11 feedback CBL, teaching and learning
  lectures, pre-clinical week role plays)
• Clinical Educator manual and workshops
  (educational philosophy, feedback and assessment
  frameworks, what can go wrong and associated
  strategies)
• Learning Needs Form (orientation to clinic and at
  the end of placement)
• Both students and educators to come into the
  session prepared (Self-evaluation forms
  compulsory)
• Students to summarise key points from feedback
• Clarify or check for shared interpretation of
  content
• Record key points gained from the session
  (reflective diary)

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Combining research Strategies for achieving
models of effective practice

• Educator invitations for student self-evaluation
  (may need further probing- ask for examples)
• Keep, Stop, Start technique
• Limit feedback to behaviours that are changeable
• Limit feedback to specific observations not
  generalisations
• Emphasise decisions and actions rather than
  students assumed intentions (limit
  hypothesising)

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Combining research Matching learning needs to
teaching goals

• Provide ongoing structured educational support to
  clinical educators
• Review the goals of teaching against established
  and evidence based educational theories and
  principles
• Review the goals and strategies of teaching
  against students needs and abilities (student
  centred)

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Applying theory to practice..

• Scenario 3rd year student
• James, the student, is a high achiever both
  academically and in the sporting field and has
  rarely received negative feedback. During his
  initial interviews with patients, James has
  demonstrated a lack of responsiveness to the
  patients comments and instead appears focused on
  adhering to a script of questions. Yesterday,
  during the physical assessment of a patient, he
  failed to perform a neurological examination
  despite the patients report of pins and needles
  and numbness. The educator notices that James is
  defensive when he is provided with informal
  feedback after working with patients. He debated
  most of the points raised and commented that I
  am doing these things, its just that youre not
  seeing them.
• 1) What strategies will you suggest to improve
  this students learning/performance?
• 2) How will you provide feedback to this
  student?

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Applying theory to practice..

• Framework for Analysis
• Interaction (one vs two way conversation,
  supervisor skill in facilitating self-analysis)
• Power/positioning dynamics (body language or
  verbal)
• Clinical educator responsiveness to students
  comments
• Content (balance of positive/negative comments)
• Supporting data (provision of examples of
  behaviour)
• Strategies for improvement
• Summarising/clarification for shared meaning

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Acknowledgements

• Physiotherapy students and clinicians at the
  School of Physiotherapy, The University of
  Melbourne
• Australian Postgraduate Award (APA)
• ANZAME Seeding Grant
• Department Human Services (DHS)

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Thank you

• Liz.Molloy_at_med.monash.edu.au
• Clare.Delany_at_med.monash.edu.au
• (C.Delany_at_unimelb.edu.au)