Acknowledgements: This monograph was developed by the MAHEC Office of Regional Primary Care Education, Asheville, North Carolina. It was developed with support from a HRSA Family Medicine Training Grant. The monograph was provided to our organization with permission to modify and use in our clinical faculty development program.

Introduction
As a clinical instructor working with PT or PTA students for a week, month, or semester at a time, you get to know your learners well. In fact, you have more one-on-one time with them than many of their faculty at school. This close working relationship offers an excellent opportunity to share your assessment of the learners’ strengths and weaknesses and help further develop their skills. In this module, you will explore effective ways of providing this feedback.
Objectives
The objectives of this module are to help you:
1. Review the defining characteristics of feedback.

2. Identify barriers that prevent preceptors from giving more feedback.
3. Outline an approach to giving effective feedback.
4. Explore how feedback can be incorporated into the busy clinic setting.

Why Feedback Is Important
Giving effective feedback is instrumental in helping learners learn. Students who receive regular feedback about their performance perform significantly better (Scheidt, Lazoritz, et al.., 1986; Stillman, Sabers, & Redfield, 1976, 1977), develop better judgement (Wigton, Kashinath, & Hoellerich, 1986), and learn faster (Hammond, 1971) than those who do not. Furthermore, learners like feedback; they identify it as one of the most important qualities of a good preceptor, second only to clinical competence (Wolverton & Bosworth, 1985). Learners often report that they want more feedback from preceptors.

TWO SCENARIOS

Throughout this module, examples will help demonstrate feedback at work. Here are two approaches to feedback that yield different outcomes.
Scenario I:
You observe a first-year physical therapy student performing a reflex test. You see her quickly bounce the hammer onto the chosen target without a word of explanation, which causes the patient to jump and say “Ouch.” You do not provide specific feedback on that episode, thinking that perhaps the student is nervous about being observed on the first day of the rotation.
On a second occasion two weeks later, you observe the same technique, which again results in patient discomfort. You tell the student, “I don’t think the patient appreciated your handling of that test – you did that before too.” The student becomes defensive, saying that you had told her she was “doing a good job.”
Later in the rotation you ask the other clinicians for their opinion, and they state the student seems self-conscious during physical exams and that her technique remains rushed and uncomfortable for patients.
Scenario II:
At the beginning of a five week OP rotation, you tell your first-year student that feedback is a key component of learning and improving as a professional. You give her a handout on how to accept and integrate feedback. On observing a reflex test administration, you see her rapidly and unexpectedly strike the patient's knee, which causes the patient to jump and say “Ouch.”
After the procedure, you comment that she did an excellent job of manual muscle testing and measuring the patient's knee flexion.You describe her use of the reflex hammer, pointing out the patient’s response of surprise and pain. You encourage her to show the patient the implement, let the patient know what she is going to do, and make slower movements.
On the next occasion, you observe that the student is careful and sensitive of the patient’s comfort and does a good job of explaining the test procedure. After the procedure, you specifically recount the changes you observed and praise her technique. She says, “Thanks, I remembered I needed to show the hammer first and I tried to take a little more time explaining its use. That made a difference.” You also remind her it can be useful to compare her findings to that of the contralateral knee and ask her to consciously focus on that part of the procedure during the next exam.
When you check in with the other staff later in the rotation, they report that the student seems very skilled in performing reflex testing and is attentive to patient comfort.
The second scenario had a better outcome than the first. The student was more open to the feedback and integrated it the next time she did the procedure. How did you act differently in the two scenarios? Let’s look at steps you can take to make the most of the feedback you offer learners.

 

The Benefits of Feedback
Feedback helps learners in a variety of ways. It helps learners evaluate their own performance. Preceptor feedback serves as a mirror in which learners can see what they do well and what they need to improve. It helps learners understand preceptors’ expectations and whether they are meeting those expectations. Furthermore, a system of regular feedback encourages learners to try new skills: they can challenge themselves, experiment with new skills, and receive guidance that helps them develop mastery before being graded.
Feedback also makes preceptors’ work easier. It provides an opportunity for the preceptor to show interest in learners’ development. It facilitates communication. Feedback helps the preceptor be proactive in identifying and addressing potential problem learning situations. (See the module on “The Difficult Learning Situation.”) Feedback makes the evaluation process easier, because the learner already knows the preceptor’s assessment of his or her performance by the time they discuss the evaluation. At the same time that a preceptor’s feedback helps learners improve, feedback from learners can help a preceptor hone teaching skills.

Characteristics Of Feedback
What exactly is feedback? In his seminal article, Jack Ende defined feedback in medical education as “information describing students’ or house officers’ performance in a given activity that is intended to guide their future performance in that same or in a related activity” (1983: 777). Feedback addresses specific actions, and its goal is learner improvement.
Ende, J. (1983). Feedback in clinical medical education. Journal of the American Medical Association, 250, 777-781.

Feedback vs. Evaluation
Feedback is sometimes confused with evaluation, but the two differ in important ways. (See Table 1.) Feedback is given as close to a given relevant event as possible, while evaluation is given at the end of a rotation. Feedback is often informal: brief sessions are fit in at appropriate times during a busy workday. Evaluation is usually performed in a more formal setting, where the learner and preceptor sit down for an “official review.”

Table 1: Feedback Compared to Evaluation


 




                                                                                                                    

 

 

 

 

 

 

 

 

What Feedback and Evaluation Have in Common

The basis for both feedback and evaluation should be objective data: specific behaviors that the preceptor has observed. However, feedback focuses on specific events or actions, while evaluation encompasses a broader level of performance and skills. The underlying purpose of both feedback and evaluation is improving learner performance; however, evaluation includes a summative grade that is not a part of feedback. (For more information on evaluating learners, see the module on “Evaluation: Making it Work")

Learners Want More Feedback
Learners often report that they do not get enough feedback from preceptors (Gil, Heins, & Jones, 1998; Irby, Gillmore, & Ramsey, 1987). Sometimes learners do not recognize the information preceptors share with them as feedback. It can help to explicitly label comments as such: “To give you some feedback, I thought your case presentation was concise, and I liked how you focused on the relevant history. On the other hand, a neurologic exam did not seem necessary. Next time, conduct a focused physical exam just as you focused your history in this case.”
Most preceptors can give more feedback than they do. Preceptors sometimes think providing feedback is unnecessary, requires too much time, or is awkward to express. Each of these barriers can be overcome.

Barriers to Giving Feedback
“Why say the obvious? The learners know how they are doing.” Actually, they often do not. When people are first learning new skills, they do not have the experience or context for judging their own performance. What is obvious to you, an experienced clinician, may still be unclear to learners.
"Is this an anomaly? That episode was probably an anomaly.” Sometimes you notice behavior that is potentially troubling, but you are not sure the learner consistently does it, and you do not want to make a mountain of a molehill. This may be particularly true at the start of the rotation. Check with colleagues and staff to see if they have observed similar behavior. It is okay to “act on the first itch” and raise the issue with the learner immediately – it is easier to prevent a potential problem than curb it once it has fully developed. (See the module on “Dealing with the Difficult Learning Situation.”) You might say to the learner, “I don’t know that this is something you normally do, but in this case I noticed that you…”, or you can ask the learner for a self-assessment and see if this behavior is addressed.
“I don’t have time. With this schedule, I don’t have time to sit down and give a lot of feedback!” Feedback does not need to take a lot of time, and it is essential for helping learners improve. At the end of this module we will discuss specific strategies on integrating feedback into the busy clinic setting.
“This is awkward. Learners get defensive.” Many preceptors did not receive much feedback in their own training. Or the feedback they received did not adequately acknowledge their skills or include strategies to improve their weaknesses. These preceptors will naturally feel that learners get defensive in a situation during which feedback was provided.
The following model can help take the mystery and awkwardness out of giving learners feedback. And the more feedback you give, the easier it gets and the less “loaded” each individual feedback encounter feels to you and the learner.

How To Give Feedback
Feedback is an ongoing process that occurs throughout a rotation -- and throughout a learner’s education. Using the “IMPROVE” strategy can help preceptors set expectations with a learner, assess the learner’s performance, and feed information back to the learner in a way that encourages improvement.

 

Table 2: Give Feedback to Help Learners Improve

 




 


 


 

​​                                    

 

 

 

 

 

​I -Identify Rotation Objectives with the Learner

The first step is preparing the learner for feedback. To facilitate a smooth feedback process, set expectations with the learner early in the rotation regarding the content that will be assessed and the process you will use to give feedback. Taking time at the start of the rotation to clarify what you expect of the learner will ultimately save you time by minimizing learner confusion and mistakes.
In an initial orientation session in the first few days of your rotation, state your expectations of the learner’s performance and discuss his or her objectives as well as the school's expectations. Together, set several specific, mutually-agreeable rotation objectives. This step identifies what to focus your feedback on for the rotation.
Talk About Feedback in the Orientation
During this initial orientation, let the learner know that feedback will be an integral part of the rotation. The learner is less likely to be “caught off guard” by your constructive criticism if he or she is expecting feedback. Describe your feedback process and discuss with the learner when feedback will be given: for example, in response to case presentations or directly observed encounters, in debriefings at the end of each day, and/ or in weekly reviews. State whether other providers and office staff will provide feedback as well. Techs and receptionists may see a different side of the learner or see the learner engaged in different tasks, and their feedback to the learner can complement your own. Ask about the learner’s prior experiences with feedback (were they negative? positive?) and keep these in mind as you start giving the learner feedback.
Train Learners to Use Feedback
Train the learner to receive and make use of your feedback. Encourage learners to set their own goals for the rotation, assess themselves against those goals, ask for your assessment of their progress, seek clarification when they are unclear about your feedback, and discuss improvement strategies for their weak areas.
Learner Suggestions on Receiving Feedback
(The following can be adapted and added to your orientation packet for new students; attached as file below)
The purpose of feedback is to gather information about your performance in a given activity in order to improve it. Receiving feedback is an instrumental part of learning. Learners who receive regular feedback about their performance perform significantly better, develop better judgement, and learn faster than those who do not. Yet receiving feedback can sometimes feel awkward or threatening. There are steps you can take to be an active partner in making sure the feedback you receive helps you improve your medical knowledge, skills, and attitudes:
Set the stage:
A) Consider feedback as an opportunity for growth rather than a threat of criticism.
B) Identify goals for yourself for this rotation, discuss them with your preceptor, and develop mutually agreeable rotation objectives.
Seek Feedback:
*Assess your progress according to the rotation objectives you set.
*Ask for feedback on your progress in these particular objectives – both in daily encounters and periodic reviews.
*Seek feedback on what you are doing well in addition to areas you can improve.
Respond to Feedback
*If a preceptor approaches you with feedback at a bad time (when you are feeling rushed or stressed), set up an alternative time, and follow up.
*Ask for specific examples if your preceptor has not offered them.
*Seek clarification on points that are unclear. Summarize the feedback at the end of the discussion to make sure you have understood the feedback.
*When receiving constructive criticism, discuss strategies to improve your weaknesses, and make a concrete plan to implement those strategies. Set up a time to revisit your progress.
*If you feel criticism is due to a personality conflict between you and a preceptor, talk to a friend or trusted adviser such as your ACCE/DCE.

Source: adapted from Rider, E. A., & Longmaid, H. E. III. (1995). Feedback in clinical medical education: Guidelines for learners on receiving feedback. JAMA, 274, 938i. Cited with author’s permission.

M - Make A Feedback-Friendly Environment

You want to create a climate in which it will be easier for the learner to receive feedback. You can take several concrete steps to foster this environment:
· Show your interest in the learner’s education. Ask about his or her background and future career goals, and show the linkages between the rotation and these goals. Learners are less likely to feel threatened by feedback from someone who seems supportive than someone who seems to be judging them.
· Make it clear that you and the learner are partners working towards a common goal of expanding his or her clinical knowledge. Seek the learner’s input as you discuss objectives for the rotation and as you assess his or her performance.
· Show your interest in what the learner does well as well as what he or she can improve. Because some learners may associate feedback only with criticism, it is a good idea to make your initial feedback positive.
· Show that feedback is a natural part of the clinical experience. Let the learner see you giving and receiving feedback from colleagues, staff, and patients. Regularly ask for the learner’s feedback about your precepting and the rotation overall.

P - Assess Performance and Prioritize What Feedback to Give

Directly observing the learner work with a patient is the best way to assess the learner’s knowledge, skills, and attitudes. Patients and learners are likely to feel more comfortable with your presence in the exam room as you observe the patient-learner encounter if you tell them about this teaching strategy in advance. Noting extraneous information or omissions in case presentations complements this direct observation of the learner’s performance.
Staff’s Observations
While you want to present information from your own observations, it is helpful to hear what other staff have observed about the learner. Your office staff may observe learner behaviors that you have not seen. They can provide you with information on the learner’s behavior that they have witnessed; you can then pay particular attention to these issues. If you observe inappropriate behavior or weak skills that seem incongruent with your other observations of the learner, it can be helpful to confer with other providers and staff about this aspect of the learner’s performance: have they noticed it as well?
Staff Feedback to Learners
You may want to encourage staff to give feedback to the learner themselves. The learner can develop a greater appreciation for the knowledge and skills of the staff, and staff may feel more invested in the learner’s education. Some staff may not feel comfortable criticizing future clinicians by pointing out negative behaviors, but all staff can reinforce positive behaviors in learners. If staff are going to provide ongoing feedback to learners, it is important that they also receive training in effective feedback and that you include staff’s role in providing feedback during the learner’s orientation.

 

Identify what priority points you want to focus the feedback on. If you provide too much feedback (more than four or five comments), it will be hard for the learner to retain any of it. Is the feedback that you are planning to give something that the learner can use to improve his or her future performance? Saying to a new learner, “You seemed really nervous in there – you were fidgeting a lot and your questions were all over the place” may not help the learner, unless you can add some concrete suggestions for how he or she might act differently in the future: “Take a few deep breaths, relax, and focus on getting to know the patient. Then focus on characterizing the symptoms.” Some behaviors are easier to change than others. For example, a learner’s quiet nature or accent is not going to change overnight. However, if it is inhibiting communication with the patients, it is important to address. A learner cannot change a youthful countenance, but might benefit from suggestions about how to demonstrate confidence and maturity if his or her young appearance seems to disconcert patients.
When and How to Give Feedback
It is best to give feedback immediately following an encounter, while the experience is still fresh in the learner’s mind. However, if the learner is feeling rushed, upset, or otherwise distracted, he or she may not be able to concentrate on the feedback. You might tell the learner you have some feedback and suggest a time to talk later in the day. The technique of “sandwiching” criticism by starting and ending with positive comments may help initially; however, be wary of using the same technique all the time. Some learners report that as they figure out the pattern, they begin to discount the positive feedback as “mere sugarcoating” of the criticism.

 

 

R - Respond To Learner’s Self-Assessment

Before you share your assessment, have the learner assess his or her own behavior in the encounter. Learners are less likely to be defensive if they critique themselves first, and you can then incorporate their observations into your feedback. This method also gives you a sense of their self-assessment skills. You might say: “Let’s talk about how that visit went. What did you like about your history and exam (or case presentation, or rapport with the patient)? What would you want to do differently next time?” Learners will often defer to your assessment, talk about their behavior in general (“My exams tend to be thorough”), or describe what the patient contributed to the encounter (“The patient presented the history readily – he was an easy patient”). Encourage the learner to assess him- or herself first and to focus on his or her own behavior in this particular encounter.
 

O - Be Objective

Describe Specific Behaviors Observed
Base your feedback on direct observations of the learner. When you describe what you have witnessed, there is less room for inferences and interpretations than when you report what you have heard from someone else. As you begin to give your feedback about the encounter, describe the specific action you observed, without any interpretation of the learner’s assumptions or intentions.
For the next several steps, let’s look at three examples:
Case 1: You are providing positive feedback to a student who has accurately identified and focused on the primary concern of a patient, scheduled for a follow-up visit, who has just lost her husband.
· You might start out by saying: “You placed your hand on the patient’s arm as she described her husband’s death last week.”
Case 2: You are providing constructive suggestions to a learner whose case presentation of a 89-year-old with multiple compression fractures did not discuss the possibly related condition of osteoporosis.
· You could start with, “You did not present information on the signs or symptoms of osteoporosis, or discuss whether you found this mentioned in the patient's medical history.”
Case 3: You are providing constructive suggestions to a quiet, reserved learner who is having trouble developing rapport with patients.
· You might say, “You took a lot of notes during the history and did not have much eye contact with the patient. You also did not ask any questions about her home life, or follow up when she said that she had been feeling stressed lately.”
Describe Potential Outcomes
Follow your description of observed behavior with possible outcomes from the behavior:
· Case 1: “She came in for a routinely scheduled treatment, but it was clear her husband’s death was foremost in her mind. It seemed that she was comforted by your gestures.”
· Case 2: “We miss an important diagnostic tool by not looking for osteoporosis. We need to know how fragile this person is -- whether we should use the appropriate precautions with her exercise plan.”
· Case 3: “You’ve talked about how you’re a quiet person and feel uncomfortable delving into patient’s personal lives, especially as a student on a month-long rotation. However, to be able to take care of your patients, you need to establish rapport and know what’s going on with them."

 

V - Validate Positive Behaviors Or Suggest Alternative Strategies

At this point reinforce positive behaviors or suggest alternative behaviors, such as:
· Case 1: “Sometimes the most important thing we can do for a patient is show our concern and sympathy.”
· Case 2: “What are the symptoms and associated risk factors that might lead you to suspect a diagnosis of osteoporosis?”
· Case 3: “Reaching out to your patients involves asking personal questions. Having good eye contact, smiling, and asking about their interests and activities helps establish rapport.”

 

E - Establish A Plan

Make a Plan to Improve Performance in Weak Areas
What does the learner need to learn or do differently next time? What strategies can you suggest to help the learner acquire this knowledge or change the behavior? For example:
· Case 2: “I’d like you to read tonight on the diagnosis and management of osteoporosis in the elderly and present it to me over lunch tomorrow. In particular, I’d like you to review the criteria you would use to select between different therapeutic exercise treatment options available.”
· Case 3: “With the next patient, I’d like you to not to take any notes during the first four minutes of the encounter – focus on eye contact with the patient. Ask two questions about their home life, and ask follow up questions to any issues they raise.”
Have Learner Summarize Feedback and Plan
To make sure the learner has heard your feedback and synthesized it, you can ask him or her to summarize it:
· Case 2: “So what will you include in the history taking and chart review of the next elderly person you see with compression fractures?”
· Case 3: “Why don’t you summarize this feedback: what are some concrete steps you can take to establish rapport, and why is this important?”

Integrating Feedback Into The Busy Clinic Setting
The “IMPROVE” strategy can make it easier for you to provide effective feedback. It helps you prepare a learner for feedback and provide specific information geared to improving future performance.
How do you implement the “IMPROVE” strategy in a busy practice? Here are a few suggestions about finding time for feedback and where it should occur.

Finding Time for Feedback

In the initial orientation, your staff can help explain the feedback process and gather information about the learner’s background (in order to set rotation objectives).
When directly observing your learner with patients, you may not need to watch a complete history and physical on the same patient. Watch the history of one patient, then go in and perform the exam with the learner. Have the learner come get you before doing the exam with another patient. Obviously the amount of supervision required with vary with multiple factors.
Time for Feedback: During the Day
We have discussed the need to provide feedback as promptly after a specific encounter as possible. But how do you do this, given your busy patient schedule? Your feedback to directly observed encounters throughout the day can be brief – prioritize 2-3 key points. You do not need to give feedback on every case presentation. However, you do want to give more extensive feedback on a regular basis. It can help to set aside 15-20 minutes each day to review cases and go over feedback and teaching points in more detail: you can do this over lunch, during a cancellation, or at the end of the day. (If you lunch in public places, beware of confidentiality issues.) During the day, jot notes to yourself about the topics you want to cover during the time set-aside. (See the module on “Integrating the Learner in the Busy Practice” for more ideas.

​Mid-rotation Evaluation

A mid-rotation evaluation complements the day-to-day feedback provided in daily debriefings. In this 30-minute exercise, preceptors and learners each independently fill out the school’s evaluation form based on the learner’s performance thus far, and then they go over it together. This mid-rotation evaluation serves to show learners your assessment of their overall performance so far, to identify areas they need to work on for the rest of the rotation, and to develop a plan for addressing the learners’ weak areas. Having learners assess themselves first helps involve them in the process and provides a good lead-in for your assessment. (See PDP module on “Evaluation: Making it Work” for more information.)
Location
Where should feedback occur? The learner is less likely to be defensive about constructive criticism when it is given in private. When possible, debrief with the learner in your office. Conduct the mid-rotation evaluation in private with minimal interruptions.

Summary
Feedback is a critical component of clinical education; it helps learners learn faster and helps preceptors both teach and evaluate more effectively. Learners want more feedback than they usually receive. Giving feedback does not have to take a lot of time or alienate learners. To facilitate a smooth feedback process, set expectations with the learner early in the learner’s rotation regarding the content that will be assessed and the process you will use to give feedback. Base your assessment and feedback on learner behaviors that you observe yourself. Make sure that the feedback you give is prompt, frequent, limited to a few priority issues that the learner can act on, objective, worded in a thoughtful way, and balanced with both positive reinforcement and constructive criticism. The “IMPROVE” strategy can help you remember these steps.


References
Ende, J. (1983). Feedback in clinical medical education. Journal of the American Medical Association, 250, 777-781.
Gil, D. H., Heins, M., & Jones, P. B. (1984). Perceptions of medical school faculty members and students on clinical clerkship feedback. Journal of Medical Education, 59, 856-864.
Hammond, KR. (1971). Computer graphics as an aid to learning. Science, 172, 903-908.

​Iryb, D. M., Gillmore, G. M., & Ramsey, P. G. (1987). Factors affecting ratings of clinical teachers by medical students and residents. Journal of Medical Education, 55, 1-7.
Rider, E. A., & Longmaid, H. E., III. (1995a). Feedback in clinical medical education: Guidelines for learners on receiving feedback. JAMA, 274, 938i.
Scheidt, P. C., Lazoritz, S., et al. (1986). Evaluation of a system providing feedback to students on videotaped patient encounters. Journal of Medical Education, 61, 585-590.
Stillman, P. L., Sabers, D. L., & Redfield, B. M. (1976). The use of paraprofessionals to teach interviewing skills. Pediatrics, 57, 769-774.
Stillman, P. L., Sabers, D. L., & Redfield, B. M. (1977). Use of trained mothers to teach interviewing skills to first year medical students: A follow-up study. Pediatrics, 58,165-169.
Wigton, RS, Kashinath, DP, Hoellerich, VL. (1986). The effect of feedback in learning clinical diagnosis. Journal of Medical Education, 61, 816-822.
Wolverton, S, & Bosworth, M. (1985). A survey of resident perceptions of effective teaching behaviors. Family Medicine, 17, 106-108.
OTHER RESOURCES

​Levy, J., & Koch, S. (1994). Bureau of Primary Health Care precepting guide: National Health Service Corps educational program for clinical & community issues in primary care. Washington, DC: US Department of Health and Human Services, Health Resources and Services Administration.
Rider, E.A., & Longmaid, H. E, III. (1995b). Giving constructive feedback. JAMA, 274: 867f.
Society of Teachers of Family Medicine. (1992). Feedback. Preceptor education project. Kansas City, MO: The Society of Teachers of Family Medicine.
Westberg, J., & Jason, H. (1991). Providing constructive feedback. Boulder: Center for Instructional Support.
Flynn, J.P. (Ed.). (1997). The role of the preceptor: A guide for nurse educators and clinicians. New York: Springer.
Hayes, E. (1994). Helping preceptors mentor the next generation of nurse practitioners. Nurse Practitioner, 19 (6), 62-66.
McHugh, M., Duprat, L. & Clifford, J.C. (1996). Enhancing support of the graduate nurse. American Journal of Nursing, 96 (6), 57-62.
Rittman, M.R. & Osburn, J. (1995). An interpretive analysis of precepting an unsafe student. Journal of Nursing Education, 34 (5), 217-221.

FEEDBACK

EVALUATION

TIMING              

SETTING

BASIS

CONTENT

SCOPE

PURPOSE

timely

informal

observation

objective

specific action

improvement

scheduled

formal

observation

objective

global performance

"grading"

Identify rotation objectives

Make a feedback-friendly environment

Prioritize the feedback you give

Respond to the learner’s self-assessment

Objective: report specific behaviors observed;describe potential outcomes of behavior

Validate what the learner has done well or suggest alternative strategies

Establish a plan to implement changes (if needed); have learner summarize feedback & plan

Feedback

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