Feedback: An essential element of student learning in clinical practice
Article Outline
- Summary
- Aim
- Benefits of feedback
- Barriers to giving and receiving feedback
- The feedback process
- Conclusion
- References
- Copyright
Summary
Clinical practice is an essential component of the nursing curriculum. In order for the student to benefit fully from the experience regular performance feedback is required. Feedback should provide the student with information on current practice and offer practical advice for improved performance. The importance of feedback is widely acknowledged however it appears that there is inconsistency in its provision to students. The benefits of feedback include increased student confidence, motivation and self-esteem as well as improved clinical practice. Benefits such as enhanced interpersonal skills and a sense of personal satisfaction also accrue to the supervisor. Barriers to the feedback process are identified as inadequate supervisor training and education, unfavourable ward learning environment and insufficient time spent with students. In addition to the appropriate preparation of the supervisor effective feedback includes an appreciation of the steps of the feedback process, an understanding of the student response to feedback and effective communication skills.
Keywords: Feedback, Student supervision, Clinical learning
Aim
Feedback is a fundamental aspect of teaching and learning. Rowntree (1987, p. 27) describes it as the “lifeblood of learning”. While the importance of feedback is widely acknowledged there appears to be inconsistency in the amount, type and timing of feedback received by students in clinical practice (Cahill, 1996, Nordgren et al., 1998, McNeill et al., 1998, Pertab, 1999, Glover, 2000, Gray and Smith, 2000, Raftery, 2001). The aim of this paper is to outline the nature and importance of feedback in the clinical learning environment. The benefits of and the barriers to feedback will be explored and finally the elements of effective feedback will be outlined.
What is feedback?
There are many definitions of feedback all of which share common characteristics. All definitions suggest that feedback is an interactive process which aims to provide learners with insight into their performance. Terms used to describe feedback may be categorised into two broad groups: constructive/corrective/negative and reinforcing/positive. In general, however, practitioners tend to use the terms negative or positive when describing feedback. When giving feedback information should include opinion and judgement about current performance and explore options for improved practice (Wiggins, 1993, Eraut, 2006). Feedback should be based on observations made while working with a student in practice and may follow a period of reflection by the supervisor. This must be an unbiased, analytical reflection of what has occurred (Wood, 2000).
Both formal and informal methods of delivering feedback to the student exist. Ideally a combination of these methods should be used to ensure ongoing and timely information is given. One informal method of feedback is on-the-spot comments which are made during practice. These are used to offer feedback on aspects of practice which are observed by the supervisor. The advantage of this method is that it is most likely to be situation-specific which ensures that important elements are not forgotten. In addition, this method lends itself to discussion of evidence-based practice which can be instantly demonstrated to the student. This opportunistic feedback is a vital element of the clinical learning experience. Many supervisors feel that this type of feedback is so much part of the day-to-day activity of the clinical environment that it is given unconsciously (Clynes, 2004). A potential drawback of this unconscious process is that it may not be regarded as feedback by the student thus negating the process (Eraut, 2006). This problem can be overcome if the supervisor refers back to these learning experiences during formal feedback sessions.
A second informal method of feedback is general conversation away from the job. While this technique may enhance collegiality its value is uncertain. Nevertheless, useful feedback may be offered. More importantly, it can foster effective relationships which may prompt the active pursuit of feedback by the student (Eraut, 2006).
For the majority of student nurses feedback takes on a more formal dimension whereby they are assigned a named supervisor who is responsible for the provision of feedback. This may include formative or summative feedback. Formative feedback is ongoing and aims to improve the learning experience. It does not involve the grading of clinical performance. Summative feedback takes place at the end of a clinical placement and includes constructive feedback and the grading of clinical performance.
Benefits of feedback
Benefits for the student
The impact of constructive feedback extends beyond the teaching and learning process. Feedback is essential for the student’s growth, provides direction and helps to boost confidence, increase motivation and self-esteem (Greenwood and n’ha Winifreyda, 1995, Atkins and Williams, 1995, Baard and Neville, 1996, Begley and White, 2003). It can help students rate their clinical practice in a realistic way (Glover, 2000). If students are not offered feedback they may compare themselves with more senior colleagues and evaluate themselves inappropriately. This can lead to decreased levels of student self-esteem which may have a negative impact on subsequent practice. It also provides a means by which the student can fit in and contribute to ward activity in a useful manner (Cahill, 1996, Glover, 2000).
Benefits for the supervisor
It is acknowledged that benefits also accrue to supervisors as a result of providing feedback. It promotes personal and professional growth and development (McGregor, 1999, Clynes, 2004). Supervisors believe that their communication and interpersonal skills are significantly enhanced through the provision of feedback (Clynes, 2004). A sense of personal satisfaction is achieved by facilitating the development of another person, sharing practice and enhancing learning (Atkins and Williams, 1995, Allen, 2002, Clynes, 2004).
Student experiences of receiving feedback
Notwithstanding the evidence that feedback is an essential component of the student learning process a review of the literature reveals significant inconsistency in the amount of feedback, praise and positive reinforcement received by students (Cahill, 1996, Nordgren et al., 1998, McNeill et al., 1998, Raftery, 2001). In fact, feedback on clinical performance is often not forthcoming and when offered, is too late, destructive, and personal in nature (Raftery, 2001). In addition, it frequently fails to concentrate on skill development and enhanced clinical performance. Some students indicate that praise can be rare, but fault finding which has a negative impact on self-esteem and confidence is not (Cahill, 1996). Students suggest that a good supervisor is someone who provides constructive criticism rather than allowing inaccurate practice to continue (Cahill, 1996). Unfortunately many students are only informed of such inaccuracies at the end of a placement when they have no opportunity to improve (Raftery, 2001). Overall students appear to exhibit maturity in their appreciation of the importance of receiving feedback and value the opportunity to concentrate on identified weaknesses thereby improving practice (Gipps, 1994, Neary, 2000).
Students tend to rely heavily on their supervisors to arrange progress interviews and offer feedback (Cahill, 1996, Daelmans et al., 2006). This may indicate that student nurses can feel intimidated by clinical staff and are subsequently reluctant to seek information and to pose questions (Moore, 1995). Alternatively it may represent a lack of initiative on the part of the students who are equal stakeholders in the feedback relationship.
Barriers to giving and receiving feedback
Conflicting demands
The supervision of students can never occur in isolation from the broader context of the clinical area in which it takes place. Thus the conflicting demands of providing patient care and student support are an ongoing problem in the provision of quality student supervision and feedback (Atkins and Williams, 1995, Dibert and Goldenberb, 1995, Wilson-Barnett et al., 1995, Twinn and Davis, 1996, Kaviani and Stillwell, 2000, Ohrling and Hallberg, 2000, Allen, 2002, Clynes, 2004). Supervisors must give priority to patient care which frequently results in minimal supervision of students. This is particularly true during periods of intense ward activity, precisely the time when students require maximum support and feedback. However, when the student is supernumerary, supervision and patient care need not be mutually exclusive. By working alongside the registered practitioner the student can learn through a process of observation and role-modelling.
Other elements which interrupt the supervisor student relationship are sick leave, night duty and annual leave. These disrupt the formal supervisor allocation systems resulting in the student being without a supervisor and receiving no feedback unless alternative systems are put in place (Watson, 1999, Raftery, 2001). Interestingly, Atkins and Williams (1995) report that nurses who are committed to supervising have fewer concerns about managing conflicting roles and responsibilities. Similarly, practitioners who are active and interested in eliciting and using feedback for their own development will be likely to engage in the feedback process with learners (Menachery et al., 2006).
Personal relationships
Maintaining positive relationships with students is valued by supervisors. For this reason some supervisors avoid giving negative feedback because they fear that criticism will affect their relationships with students. In addition many nurses are uneasy with the process of delivering feedback (Raftery, 2001, Dohrenwend, 2002, Clynes, 2008). In particular supervisors report the difficulty they experience in giving negative or constructive feedback. Nevertheless nurses realise the importance of offering feedback to students and where possible attempt to do so as they are aware of the consequences of not providing feedback. When negative feedback is withheld, supervisor-employee relationships remain superficial and lack the necessary flexibility to tackle sensitive issues which may subsequently lead to aggressive behaviour due to an avalanche of pent-up criticism (Dohrenwend, 2002).
Preparation for giving feedback
Preparation for the role of supervisor may also affect the nurses’ ability to give feedback. The need to prepare staff for the role of supervisor/supervisor is well recognised (Wright, 1990, Philips et al., 1996a, Philips et al., 1996b, Kaviani and Stillwell, 2000, McCarthy and Higgins, 2003). Simply assigning named practitioners to students is no guarantee of their ability to provide effective feedback and thus give the student the opportunity to improve practice (Higgins, 2000). It cannot be assumed that a clinically competent practitioner will have the necessary skills to give feedback to students (Kaviani and Stillwell, 2000, McCarthy and Higgins, 2003). The importance of specific training in providing feedback cannot be underestimated. Many training programmes focus on the documentation that aids the assessment process and the feedback process is poorly addressed or overlooked.
The feedback process
It is widely acknowledged that feedback is more likely to be accepted and result in improved practice if the information is appropriately presented to the student (Russell, 1994, Newstrom and Davis, 1997, Dohrenwend, 2002). The effective delivery of feedback is a multifactorial process which begins with preparation of the supervisor in the competent delivery of feedback. Further elements include establishing objectives with the student, timing of the feedback, the environment, the language and format used and the readiness of the student to receive feedback.
Preparation of the supervisor
Prior to embarking on the role of student supervisor it is essential that the nurse is educated and trained in a method of feedback delivery. Formal training should include a period of self reflection in order that any personal attitudes and biases regarding supervision can be acknowledged. Discussion of personal experience of receiving feedback, identifying positive and negative aspects is required. Experience of providing supervision to date, with emphasis on problem solving in the role, should be explored. The use of role play can assist the nurse to work through challenging feedback situations in a safe environment. There does not appear to be agreement on the length of time required to train a supervisor effectively and programmes vary in length from a few hours to a number of weeks. Generally it appears that in-house workshops are approximately one to two days in length (Kramer, 1993, Bain, 1996). It is also anticipated that a significant number of nurses will have completed a teaching and assessing programme as part requirement of degree or graduate diploma programmes.
Understanding the student response to feedback
A further consideration for the nurse preparing to deliver feedback to students is the need to gain an understanding of how students respond to feedback. Factors such as a student’s self-esteem (Young, 2000), relationships in the workplace and the expectations of the learner affect how the feedback is received (Eraut, 2006). Supervisors need to be cognisant of the relationship between self-esteem and receipt of feedback. It appears that students with high self-esteem have a positive attitude to receiving feedback and being assessed (Young, 2000). Furthermore students with high self-esteem have the ability to appreciate constructive comments and understand that the information relates to performance. Conversely, students with lower self-esteem tend to interpret constructive comments more negatively and often perceive them as personal in nature.
A significant consideration when giving feedback is an understanding that feedback given is not always the same as feedback received (Eraut, 2006, Koh, 2007). It is important to remember that information the supervisor regards as a comment on performance may be perceived by the recipient as a personal slight. Clynes (2004) notes that students often do not understand that concerns highlighted by the supervisor are directed towards ensuring improved clinical performance and quality patient care. In order to assess how the information has been assimilated by a student during a feedback session, it may be useful to have a summary discussion during which students are encouraged to reflect on the feedback and outline their interpretation of its content.
The relationship the student has with the supervisor will influence the receipt of feedback. When a student respects their supervisor and believes that the supervisor knows them well they are likely to value the information received (Gillespie, 2002). In addition, this type of supervisor/student relationship may encourage the student to seek feedback regularly (Eraut, 2006).
On occasion feedback to students may be impeded due to supervisor related factors. Despite careful preparation, anxiety and unease with the process can inhibit the delivery of feedback to the student. In extreme cases the supervisor may delay or completely avoid an evaluation meeting with a student for fear of a negative response or over-reaction to criticism. This is particularly true in the case of a novice supervisor or when difficult feedback has to be given (Clynes, 2008). Despite such fears, for a student to progress and in the interest of best practice, it is essential that the feedback session takes place. Provided the supervisor is empathic, chooses appropriate assertive language and provides negative feedback within the context of a positive assessment, no responsibility should be taken for how the student reacts when the feedback is given (Baard and Neville, 1996). Naturally students may be disappointed with constructive feedback and the supervisor must ensure that the session includes a positive action plan for how to move forward and improve performance.
Environment
As discussed, informal feedback may take place in, or removed from, the practice setting. When giving formal feedback to students it is essential that sufficient time and space are allocated to the process to ensure that all aspects of practice can be discussed without interruption. Feedback should be given in a quiet, private environment. An informal room layout will promote two-way discussion of the student’s performance and should foster openness and honesty. Ideally, the use of ward treatment rooms should be avoided due to constant interruptions which can be stressful for both student and supervisor.
Delivering feedback
Jerome (1995) describes the feedback process as occurring in four stages (Fig. 1).
Figure 1.
The feedback process.
At the beginning of a clinical placement the learner and supervisor must work together to establish learning objectives as feedback will eventually be based upon these (Wood, 2000). When offering negative or critical feedback it may be useful to use the “sandwich” technique (Dohrenwend, 2002). This method consists of providing negative feedback sandwiched between two specific pieces of positive feedback. This method is particularly useful when working with junior students and students with low self-esteem. In situations where there is a very healthy supervisory relationship it is not always essential that all praise or criticism needs to be sandwiched and on occasion it may be more appropriate to offer praise and criticism independently (Dohrenwend, 2002). Mature students with prior nursing experience do not appear to be overly concerned with the manner in which feedback is given unlike younger students who may be more sensitive to criticism (Lee et al., 2002).
Wiggins (1998) describes the best feedback as being highly specific, and descriptive of what actually occurred. Information, including examples from practice, should be clear to the student and offered in terms of specific targets and standards. Feedback should focus on evaluating behaviour and work performance and not on the student’s character (Russell, 1994, Baard and Neville, 1996, Newstrom and Davis, 1997, Dohrenwend, 2002).
The importance of asking for the student’s self assessment before giving feedback cannot be underestimated as it provides the supervisor valuable insight into the student’s ability to evaluate his or her own performance (Pugh, 1992). The process of delivering feedback is considerably easier for the supervisor when the student identifies their own practice limitations (Clynes, 2004).
In considering the delivery of feedback Myrick and Yonge (2002) suggest that gentle rather than harsh feedback encourages students to become confident and competent in developing a plan that achieves safe and effective nursing care. Moreover, by approaching the student with sensitivity and taking on a helping, rather than corrective role, the supervisor assists the student to examine the prioritisation of their work. Feedback should be given in private, when there is ample time and opportunity for clarification and discussion and with due consideration for the student’s feelings (Hewson and Little, 1998, Clynes, 2004, Kelly, 2007). Conn (2002) considers it important not to confuse feedback with praise as students and teachers often do. While praise may be conducive to developing a positive relationship between supervisor and student, it may not provide the student with specific insight into their performance.
Conclusion
Feedback on clinical performance is essential for effective student learning in clinical practice. However, students report variable experiences of receiving feedback while on practice placements. This may be attributed to a number of factors including the ward environment and the readiness and ability of the registered nurse to give feedback. Preparation of the registered nurse in the provision of feedback to students is paramount. Awareness and understanding of the elements of feedback delivery can aid the process and ensure that both supervisor and student have a positive interactive experience.
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PII: S1471-5953(08)00020-6
doi:10.1016/j.nepr.2008.02.003
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