Feedback and reflections:
what are the techniques &
How do I assess?
Dr Karuna Sree P
Associate Professor
Dept. of Pharmacology
Contents
• What is feedback?
• How to deliver feedback?
• Barriers & concerns in providing feedback
• Novel changes in providing feedback
• What is Self Reflection?
• How is it important?
• Take home message
Why feedback?
• Keeps learner on course to meet goals
• Allows learner to adjust course to meet goals.
• Support and foster students as self-directed learners
NEEDS
What ought to be
What is
What is Feed back
“Feedback refers to information describing a learner’s performance in
a given activity that is intended to guide his/her successful
performance in that same or in a related activity.”
- Jack Ende, JAMA, 1983
Types of Feedback
Constructive feedback
Positive feedback
Negative feedback
Another type of classification:
Brief
Formal
Major
How to deliver the feedback
Old feedback sandwich
New feedback sandwich
(Do ask; Do tell)
ASK
(Self reflect)
TELL
ASK
Checklist: The Feedback Dialogue
Ask learner to assess own performance first :
• What went well and what could have gone better?
Tell what you observed:diagnosis and explanation
React to the learner’s observation
Include both positive and constructive elements
Give reasons in the context of well-defined shared goals
Regulate quantity
Ask about recipients understanding and strategies for
improvement,
What could you do differently?
Give own suggestions
Perhaps even replay parts of the encounter - show me
Commit to monitoring improvement together
Pendleton model Learner
explains
strengths - Self
• Four key steps: Teacher
Learner agree
performs /disagree,
discuss
Learner Learner explains
summarizes, deficiencies -
teacher approves Self
Learner tells Action Teacher agree
plan, teacher /disagree, discuss
approves / modifies
Who can contribute?
Self
Peers
Faculty
Other team members
“360-degree feedback”
When to give feedback
During/soon after patient contact
End of each half day or day
Mid rotation
End of rotation
How to collect the feedback ?
Oral / one to one
Questionnaires
BEFORE Giving Feedback:
Prepare Effectively
Plan what you will say
Is the information specific or general?
Think about who else you need to collect information from
If feedback is second hand, do you have enough specific, behaviorally
based information? Was it documented by the other person?
Remember SORT (Specific, Observational, Relevant, Timely)
Faculty barriers to feedback
Time constraints
Absence of standards for competent performance / lack of training
Lack of direct knowledge of learner’s performance
Discomfort in giving constructive (negative) feedback
Unfamiliar with providing effective feedback
Learner concerns with feedback
Non-specific - does not help learning or performance
The comment “Keep up the good work” does not help me.
Personal - statement about worth or potential (embarrassing or humiliating) -
more negative feedback
Not timely - too late to change performance
Not progressive - no sense of what they have achieved in progress towards a goal
or have yet to achieve.
My teachers don’t provide feedback.
Traditional
CBME
curriculum
Teacher centered - Learner centered -
unidirectional bidirectional
• Outcome may or may not be • Focus on outcome
achieved • External feedback present
• No external feedback • Focus on socio-cultural
• Sociocultural context, context and environment for
environment, reflections are improved relationships
not focussed • Reflections are the part of
feedback
Changes in delivering Feedback …
• Newer definitions of feedback emphasize
• “Its impact on recipients; until learners act on feedback, the feedback
loop remains incomplete.”
New Feedback models
• R2C2 Model (relationships, reaction, content, and coaching)
• Educational alliance model
• Tango model
• Depends on 3 theories
• Sociocultural theory
• Politeness theory
• Self determination theory
Strategies of Effective feedback
1.Establish a positive learning climate 4.Foster a growth mind-set among
and be a professional role-model learners rather than fixed mind set
2.Use direct observation of 5.Encourage feedback seeking
performance to generate feedback behaviour - goal orientation for
data learning
3.Facilitate reflection and informed 6.Promote learner initiated action plans
self-assessment – Johari Window for behavior change
Feedback Feedback
Provider Recipient
Feedback
Institutiona
relationshi
l Context 7.Establish an educational alliance as
9. Ensure appropriate attention to learner self- p
efficacy mentioned by Telio et al / Sargeant et al
10. Establish a continuous practice improvement R2C2 model / Bing-You et al Tango
environment dance.
11. Promote optimal balance of supervision & 8.Encourage teachers and learners co-
autonomy
create learning opportunities for
12. Emphasize a feedback culture that enhances
professional growth behaviour change
A participatory design feedback loop : Co-creation of
learning opportunities Learners frame
learning goal &
discuss with
Loop re-enters teachers Teachers –
through directly observe
discussion of new the performance
learning goals of learners
Learners Initiate
Teachers Facilitate Feedback
Learners & conversations –
teachers co-create teachers &
learning learners plan &
opportunities de brief
Teachers
Learners prepare
facilitate
Action plans with
reflections &
the help of
informed self
teachers
assessment
Reflections
• Reflections includes a framework for reflection, involving critical
thinking, exploration of personal and emotional experiences, and
examination of the impact of actions.
• Mann and colleagues
Reflections : Where & How?
• Where : At home or in class
• How : oral / written / e-reflections
• Oral – well suits for reflection in action
• Written /e-reflections – suits for reflection on action
Models of Reflection
• What happened?
• So what?
• What next?
• Reflection leads to growth of the
individual—morally, personally,
psychologically, and emotionally,
as well as cognitively.
Lyne Ménard, Savithiri Ratnapalan. Reflection in medicine Models and application. Canadian Family Physicianol. 2013;59:105-7
“Without feedback, mistakes go uncorrected, good
performance is not reinforced and clinical competence
is achieved incidentally or not at all.”
- Jack Ende, 1983
Take home Message
• Feedback and Reflections are essential.
• Build Longitudinal relationship
• Modify existing feedback tools / models
• Determine the right steps for feedback exchange
• Deliver ongoing, external feedback
• Institutions :
• Train the feedback providers
• Improve the overall feedback culture
Feedback and Reflection
References
• Ramani S, Konings KD, Ginsburg S, van der Vleuten CPM. Twelve tips to
promote a feedback culture with a growth mind-set: Swinging the feedback
pendulum from recipes to relationships. Med Teach. 2018;1–7.
• Bing-You RG, Varaklis K, Hayes V, et al. The feedback tango: an integrative
review and analysis of the content of the teacher-learner feedback exchange.
Acad Med. 2018;93(4):657–63.
• Subha Ramani, Karen D. Könings, Shiphra Ginsburg, Cees PM. van der
Vleuten. Feedback Redefined: Principles and Practice. J Gen Intern Med.
2019:34(5);744–9
• Louise Aronson. Twelve tips for teaching reflection at all levels of medical
education. Medical Teacher. 2010;1-6.
Than Q
