Promoting high-quality feedback

Teachers play a key role in residents’ competency development by providing feedback to support learning. This article introduces a short tool, available at CFPlus,^* for reviewing formative feedback given to learners by teachers. This tool fosters teachers’ reflections about the quality of feedback they provide to learners and emphasizes key points regarding the value of feedback for learning.

Background

As we move toward implementing competency-based medical education, it is becoming clear that the teacher is the most important assessment tool. Workplace-based assessment has gained acceptance as an assessment strategy by focusing on authentic day-to-day work, as well as relying on observation-based feedback. Teachers’ abilities to provide direct observation, feedback, and mentored deliberate practice are of primary importance in facilitating residents’ competency development.¹ Assessment systems in many postgraduate family medicine training programs across Canada use daily workplace-based assessment forms (field notes [FNs]) to document feedback teachers provide verbally in the clinical setting. (An example of a high-quality FN is available from CFPlus.^*) The purpose of FNs is 2-fold: to document and reinforce verbal feedback offered to residents; and to allow program directors, academic advisors, and competence committees to collate multiple low-stakes assessments completed by different teachers over time and across contexts to inform periodic summative, entrustment, and competency attainment decisions about residents.² Although the quantity of the daily assessments is important in painting an increasingly detailed picture of learner competence, the quality of feedback in daily assessments is also critically important as a catalyst for learning and allows formative assessment to truly drive learning.^1,3 Competency builds throughout residency, and preliminary work in our program has shown that residents identify working in community practice as the place where their professional identity grows exponentially. Therefore, it is critical that effective feedback occur throughout the residency training program, including while on community rotations.

Evidence and best practices

Formative assessment coupled with feedback is intended to stimulate learning and is integral to competency-based medical education.^1,3 Feedback can affect many different phases of the learning cycle. Preliminary work in our program indicates that residents believe high-quality feedback can change and improve practice, impart new information, motivate learners, confirm that learners are on the right path, promote reflection, and be corrective in nature. Providing feedback that intentionally enhances and supports education by encouraging learners’ reflection in action can be challenging for teachers.³ The literature suggests there are opposing perceptions about formative feedback. Learners often report that feedback is given infrequently and ineffectively, whereas teachers report giving frequent and adequate feedback.⁴ Faculty development focused on enhancing the quality of feedback is critical for addressing this disconnect.

Feedback is best embedded in the instructional process, daily work flow, and institutional culture.^3–5 Making feedback and workplace-based assessment routine, frequent, and expected normalizes the process and reduces learners’ and teachers’ anxiety around feedback in general. Feedback should link to directly observed performance, as learners are more accepting of this type of feedback and less likely to discount it.^4,6 Learners also tend to accept feedback more readily when its relevance can be demonstrated.^5,7 This can often be achieved in workplace-based assessment with explicit reference to residents’ clinical work.

The elements of high-quality feedback that have the greatest effect on learning are well documented in the literature.^3,5,6,8 There is evidence that teachers’ awareness of these elements of effective feedback can enhance the quality of feedback offered.⁸

For maximal educational benefit, feedback should be timely. Learners will invest more effort and resources in tasks when feedback is well timed.^3,6 Further, learners report higher levels of satisfaction when provided with narrative feedback.⁴ Specifically, the richness of narrative comments can convey the relevance and depth of context-specific meaning in ways that checklists cannot.^9,10

Feedback is considered to be most effective when phrased in a positive or supportive manner so as to promote respect and trust in the teacher-learner relationship.⁶ Avoiding personal comments and comparisons with other learners and focusing instead on task performance and observed behaviour also increases acceptability for learners.⁶ Feedback that is specific has been found to be more readily assimilated.⁷ Ultimately, the most effective feedback is clearly stated, reinforces what has been well done, identifies what can be improved, and includes specific strategies for improvement.^3–6

To be most effective, feedback should relate to specific standards for performance and clearly identify whether performance meets those standards.^6,7 Descriptions of standards for performance can be based on training objectives or entrustable professional activities. Ultimately, standards for performance promote understanding about expectations for teachers and learners and support criterion-referenced assessment. They can inform teachers’ judgments about resident performance and guide the formulation of feedback to support growth with descriptions of next steps.

Novice and more advanced learners have different feedback needs, and tailoring the sophistication of the feedback to the level of the learner is ideal. For the novice learner, concrete and basic feedback about a single skill is most helpful. In contrast, more advanced learners require feedback that focuses on higher-order learning tasks. These tasks generally require more complex, integrative skills such as problem solving, reasoning, assessing, concluding, analyzing, and evaluating. Optimally, high-quality feedback directs learners to higher-order learning goals by pushing them beyond the tasks they are most comfortable with toward those that might be new and that they have yet to manage independently.^9,10

Tools and resources

The FN review tool was developed after a thorough review of the literature on feedback. A working draft of the tool was developed by one of the authors (J.M.G.). The tool was validated by a subset of the authors (J.M.G., L.A.M., and U.L.) by independently rating a set of 40 daily workplace-based assessment forms and comparing results, discussing disparities, and adjusting the wording of the tool to clarify meaning and improve understanding. This process of fine tuning was repeated until consensus among reviewers was reached regarding utility and applicability, and all were satisfied the tool would produce similar results when scored by different people.

The tool is designed to deliver key messages about high-quality formative feedback, highlighting the fundamental role of feedback as a teaching tool as well as providing some inspirational messages and tips for completing FNs. To promote guided self-reflection, a table is included as part of the tool for teachers to review the features of high-quality feedback and score their own FNs for the presence of these features. To facilitate teachers’ use of this personal reflection tool, we provide hard copies of the tool along with printouts of the last 20 FNs they have written. As an added incentive to complete this guided self-reflective process, this activity might qualify for 5 Mainpro+ certified Self-Learning credits through the College of Family Physicians of Canada’s Linking Learning to Practice program. Teachers have successfully submitted their reflections for credits and, informally, those who have used the tool report it to be an enlightening experience that has changed the way they approach documenting feedback for learning. In the future we envision the tool being used as a reflective activity as part of faculty development sessions. As well, the tool would be accessible online as part of our FN assets for use by any teacher. Although this tool was designed for use in the Department of Family Medicine at Queen’s University in Kingston, Ont, we believe some very minor adjustments would make it applicable to other postgraduate medical education settings.

Conclusion

This article introduces a convenient tool for reviewing feedback given to learners by teachers. It was designed using the evidence-based features of high-quality feedback. The tool fosters teachers’ reflections about the quality of feedback they document and emphasizes key points regarding the value of feedback for learning. It allows teachers to review a set of recent daily assessments (written by them) and prompts guided self-reflection on the quality of feedback they offered. The ultimate goals of this undertaking are to motivate and inform best practices for teachers providing feedback to learners, and shift the culture of assessment by offering on-demand, personally relevant, accessible faculty development for academic and community-based teachers about the value of high-quality feedback.

TEACHING TIPS

• Feedback should be timely and supported by narrative comments. The tone should be positive and supportive.

• The narrative should be specific and describe behaviour in unambiguous language; reinforce what has been done well; identify areas to improve; and include specific strategies for improvement.

• Feedback should relate to specific standards. There should be congruence between the learner level and the sophistication of feedback, ideally directing learners toward higher-order learning goals..

Teaching Moment is a quarterly series in Canadian Family Physician, coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Miriam Lacasse, Teaching Moment Coordinator, at Miriam.Lacasse@fmed.ulaval.ca.