SAFILT Core Skills: Giving Supportive Feedback

Giving constructively critical feedback is the central tenet to the debriefing process. Feedback is a formative process, reflective and developmental. It provides an anchor for insecurity, enabling learners to more accurately locate themselves at a point in the learning process. However, feedback exists under a number of guises, both directive and non-directive. Being able to apply the differing types of feedback at the appropriate times is useful as junior doctors make the transition from FY1 to FY2

Defining your approach to giving feedback can be decided as part of your setting of aims or objectives or can be utilised more flexibly, switching from directive and non-directive forms as deemed necessary.

The choice lies in the educational goals that the facilitator wishes to achieve.
Poorly constructed feedback can result in negatively influencing learner’s future engagement in simulation or experiential learning

Introduction

Providing feedback linked to outcomes in such ways that the learner does not perceive it as an assault on personal deficiencies is an important skill. While it is important in debriefing to construct a culture of self-direction and of learning through error, facilitators also need to be mindful of their professional and social responsibilities to the scenario participants.

As such finding the balance between self-directed and directed learning needs to be carefully considered. This is more than just being aware of the conditions for engagement in feeding back from scenarios: It requires levels of emotional intelligence, for if learning is allowed to become wholly self-directed it will at some point clash with institutional expectations (Brookfield, 1998)

Feedback therefore needs to be delivered in ways which are constructive, critical, and where necessary corrective.

Giving Feedback

Quilligan (2007) suggests that poorly thought through or negative feedback can negatively influence learner’s engagement in future experiential learning. Conversely, effective and non-judgmental feedback can have the opposite effect. Further, three key points for effective feedback are suggested:

Feedback must be descriptive
Comments about what is working and what could be developed need to be supported
The way feedback is given is more important than what is said

Whilst there is no doubting the value of all of these, it is point 3 which is the key to success: Feedback perceived as a criticism as opposed to a supportive attempt to help development is unlikely to be effective.

Feedback is challenging. Quilligan (2007) goes on to suggest some of the reasons for this.

Feedback needs to address individual learner needs
Finding the right balance is difficult
Information needs to be limited and useful for learning
Timing the feedback appropriately
Providing descriptive feedback is challenging

Guidance on giving effective feedback can be found here:

ACCESS VIDEO FILE GIVING_SUPPORTIVE_FEEDBACK_1 NOW USING THE BUTTON AT THE TOP RIGHT OF THIS WEBPAGE.

Feedback can be given as a direct form of feedback, as Lorraine shows in the above clip.

Ensuring Feedback is Relevant to the Task Set

Providing feedback linked to outcomes in such ways that the learner does not perceive these as personal deficiencies is an important skill. A useful starting point is to ask the learner to give an assessment of their performance, ultimately leading to a discussion and sharing of experiences related to the objective and the ways it might be achieved. What this also does is to direct the feedback in such a way that it meets the learner’s agenda. Being able to balance the discussion with the peer group involved is also important as it sets the tone for mutual respect and value.

Learners may also come from varying types of learning and traditions. Their experience of how learning takes place, coupled with their own learning style may affect their ability to learn through feedback. Reinforcing strengths and developing these into questions as to how they might be further developed may be a helpful and beneficial way forward.

An example of feeding back positively can be found in the electronic version of this pack, along with some questions on what makes this a good example of feedback.

ACCESS VIDEO FILE GIVING_SUPPORTIVE_FEEDBACK_2 NOW USING THE BUTTON AT THE TOP RIGHT OF THIS WEBPAGE.

This is demonstrated perfectly in the two examples in this clip where Ian prompts the participants to ask why the scenario was ended and then follows this up by asking them why certain aspects of practice were not covered in detail.

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What we can also observe here is the way in which Ian sits quietly and allows the feedback from a peer to develop. This is good use of being silent through conversation without feeling the need to place an authoritative stamp on the debrief.

The Feedback Sandwich

The Feedback Sandwich is a basic but very useful format for feeding back following scenarios. In essence this approach provides a positive ‘first slice’ followed by a critical ‘filling’, which is then followed by a positive ‘topping’. The underpinning principle behind this approach is that in focusing on the positive the process becomes more one of feedback rather than one of judgment or evaluation. A further component to this is the way in which the ‘filling’ is made. The aim is not to point out individual deficiencies (though this may be necessary occasionally) but to foster a critical and constructive climate for reflecting on practice

An example from debriefing practice: The feedback sandwich applied

Describing

A chronological outlining of the events occurring in the scenario – this could be described as building a scaffold for the rest of the debrief to be built inside

Analysing

This is the stage of constructive criticism and individual and group reflection on the scenario – the way in which practices and actions can be improved

Applying

This incorporates collective and guided generation of theory applied to practice

Some words of caution: It is easy for the approach above to become formulaic, so rather than use this guide literally, it is better that it underpins the feedback process. Secondly there are criticisms that in using the feedback sandwich, the beginning and end parts tend to be the most remembered, while the middle section gets lost in the process. Care needs to be taken to ensure the crucial middle section does not become erased from the learning process. Asking the participants to summarise for themselves what they have learned will support this.

Enabling self-evaluation and reflection

Feedback should be a catalyst to self-evaluation and reflection. That which is already known and understood is reassembled and reworked through a reflective engagement, exploring the meaning and implications of an action or experience.
Branch and Paranjape (2002) suggest that Reflection as a process is an imperative for Medical Education: An opportunity to grow emotionally, psychologically, and personally. Focused reflection is more than just navel gazing. It is a combination of skills, values, knowledge and attitudes applied to the learner’s cognitive framework.

Branch and Paranjape (2002) further note that there is a tendency in medical education towards pragmatism and concrete thinking. Elaboration in discussion is therefore a key component to deeper conversation and learning, exploring the subject from different angles. Posing reflective questions through debriefing is the precursor to reflective thinking.

Giving Effective Feedback

Quilligan (2007) identifies ten points which can be applied to feedback, which are summarized below. Each of these points is equally applicable to simulation debriefing itself.

Establishing an appropriate interpersonal climate
Establishing mutually agreed goals
Relating feedback to the learners agenda, not the teachers
Eliciting the learners thoughts and feelings
Reflecting on observed behaviours
Being non-judgemental
Relating feedback to specific behaviours
Offering the right amount of feedback
Getting the learner and/or group to offer suggestions for improvement
Giving well-timed feedback and allowing the learner the opportunity to try again (p.101)

Categories of Feedback

Branch and Paranjape (2002) categorise feedback as acting in the three capacities of Brief Feedback, Formal Feedback, and Major Feedback

They define that ‘Brief feedback disciplines the teacher to make highly concrete, useful suggestions’ (p.1185). In so doing, by suggesting to the learner that they are giving feedback the effect is instant. It has been made explicit to them. Formal feedback is delivered in a specific period of time allocated to the learner or group. It may be connected to practice or to a teaching exercise, and importantly the time put aside and the setting need to be conducive to the nature of the feedback. The third category, Major Feedback, is defined by its scheduling and pre-planning, such as at a mid-point in the learner’s experience. Items prioritised can be things such as performance to that point and future corrections and needs. Brief and Formal feedback are the two mostly likely modes of feedback in the simulation setting. Learners may not recognise feedback if it is implicit in the discussion. It is only when it becomes explicit that they recognise it as more than just a conversation.

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References and further reading

Brookfield S.D (1998) Understanding and Facilitating Adult Learning. Open University Press. Milton Keynes

Quilligan S. (2007) Communication skills teaching: the challenge of giving effective feedback. The Clinical Teacher 2007 (4) pp.100-105

Branch W.T. Paranjape A. (2002) Feedback and Reflection: Teaching Methods for Clinical Settings. Academic Medicine Vol. 77 (12) Dec 2002 Part 1