Rich Bregazzi on feedback

The Purpose of Feedback

Feedback, modification of a process etc. by its own effects.

The availability of information that enables learners to evaluate and so modify their own performance is critical to learning. Feedback in this context is specific, factual information about current performance and its effects that enables the learner to make decisions about future performance.

The constructive provision of feedback is one of the most effective ways to improve any kind of performance.

Positive feedback confirms and reinforces acceptable performance. Negative feedback helps learners to recognise and analyse unacceptable performance. Both should leave the learner able and willing to improve, with self esteem intact.

Sources of Feedback

Information about performance is available to learners from the job itself, from patients, the work team, trainers and other colleagues.

Feedback should happen routinely during everyday work, as well as during more formal review sessions with the educational supervisor. It can be asked for by the learner or volunteered by appropriate people. The more that people in the workplace talk openly about ways to improve performance, the easier and more natural such conversations become.

Having explicit standards of work gives learners criteria against which to evaluate their own performance. Learners also compare their performance with that of colleagues, and are guided by the norms of their particular workplace.

The Boundaries of Feedback

The boundaries within which feedback is likely to be accepted by the learner are defined by the reason for the relationship between the learner and the person offering feedback, the nature of that relationship, the abilities for which the person giving feedback is respected, and the learning goals of the learner. The role of educational supervision and the process of managed learning provide a framework and a focus for giving feedback.

“He can do the job, but his attitude’s all wrong…”

Feedback is about performance. You may wish to speak to a learner about his or her attitude, personal habits, dress sense or whatever, but do you have permission to do so within the boundaries of your relationship? Perhaps you do, if performance is being affected. If so, try to get to the attitude via the performance, not the other way round.

Attitudes that underpin professional conduct are influenced by the example of colleagues, and the opportunity to explore and reflect upon beliefs and behaviour in a challenging yet supportive environment. There may be roles here for the educational supervisor as critical friend, counsellor, sounding board or role model, but these go beyond the boundaries of feedback. Attempting to deal with personal issues that affect performance is a sensitive area and may require referral.

Feedback During Everyday Work

Effective learning in the workplace involves a high level of open, honest and straightforward communication. People should be told about progress, expectations, or any difficulties that affect them. They should not be left to find things out for themselves. Feedback should be a commonplace activity that is valued and sought, recognised and accepted for what it is. There is nothing wrong with introducing feedback with the words “Right, now for feedback…”

Learners should obtain feedback from appropriate people

Learners need to know what others want from them and their views on whether they are delivering it. They should find out about what they have to improve by getting feedback on their work from appropriate people. They should be encouraged to ask, and to check that they understand what is being said. The response to their questions should leave them willing to risk asking for feedback again.

Be constructive about mistakes

When things go wrong people need to know what it was, and to understand how it happened and any consequences. They may know this already. Once you are satisfied that they do, it is counterproductive to labour the point. Concentrate on what can be done. Use mistakes to help learners change how they do things in order to improve.

Recognise achievement

Give precise praise for things well done. General praise is often dismissed and does not reinforce any specific behaviour. Reward development with recognition, try to give people responsibility that matches their achievement.

Structured Feedback

The outcome of feedback should be a motivated learner with a clear view of where they are and what they need to do.

Structured feedback should focus on what is going well, what needs to be improved and lead to what actions need to be taken. Feedback should:

  • Start positive, indicating specific achievements, strengths, and standards that have been met.
  • Move to areas of need, indicating the difference between actual and required performance.
  • Agree necessary steps for improvement.
  • Always encourage progress and leave people able to move forward.

Remember that people become cynical about faint praise followed by detailed exposure of their weaknesses. Be genuine, balanced and allow a response; feedback should be part of a dialogue.

You should notice how your feedback is received, and whether it results in appropriate behaviour.

Handling Negative Feedback

Telling someone that their performance needs to improve does not guarantee either that they will agree with the judgement or that, henceforth, their performance will improve. Negative feedback can have a considerable emotional impact. It can motivate, but it can also cause apathy or anger. Helping people evaluate themselves and find their own way forward has a greater chance of achieving the desired outcome.

First, make sure that the setting is appropriate. You may require privacy and freedom from interruptions (including bleeps, telephones and people). Also pay attention to the physical layout of any meeting and what this says to the learner about its formality and his or her status. This is not a disciplinary procedure, it is about support for learning.

Negative feedback should be objective, addressing actions and their effects, not the person: “This procedure took 30 minutes rather than the usual 5 minutes, during which we were not able to treat the other patient”; not “You were hopelessly slow”.

The basic approach remains the same: start positive; move to areas of need; agree steps for improvement; encourage progress. Try to help learners reach decisions for themselves, perhaps adding your suggestions and offering help if appropriate. Aim for agreement, summarise key points and check commitment to decisions. Both participants should be clear about what has been decided and what they have to do about it.

Handling Disagreement

If they disagree with feedback learners may simply tell you, or they may indicate this in other ways. You need to be receptive to signs that suggest when this might be happening, things like:

  • Negative body language.
  • Placing blame, on others or on circumstances.
  • Surfacing of emotion.

Continuing with negative feedback once the learners agreement has been lost is fruitless. It may even devalue feedback already accepted. The learner needs to be brought to a point where the problem is accepted before moving onto solutions. This may mean returning to some common ground and working from there, giving further positive feedback and trying again, or ascribing positive motivation to the learner: “You put a lot of time and effort in on this patient, which meant that x and y were achieved. But the anaesthetists did need to know about the earlier incident so that they could do such and such”.

If the learner reacts emotionally to what has been said, there are three choices.

You can ignore the emotions, although they are unlikely to go away. It is better to acknowledge what is happening, “I can see that you are upset about this”, and take it from there.

You can try to deal with the emotions. In some cases further explanation, positive feedback or promises of action will suffice. In others, the learner needs to be given the chance to express and dissipate the emotion. Then you need to establish the causes of the emotion, and only then can you usefully move towards resolving the problem. This may be time consuming and it can make matters worse. If handled with skill and sensitivity, however, it may allow you to continue.

Sometimes, rather than risk losing what has already been agreed and perhaps damaging the relationship, it may be sensible to conclude the session with a view to returning to the problem at a later date. This is OK as long as the consequences of the problem remaining in the short term are acceptable. If they are not, you may have to take a more directive role.

Verbal Communication

In our context the purpose of verbal communication is to gather and give information, with a view to improving performance. At its best, it is used to enable learners to evaluate their own performance and to establish their own learning plans. This is likely to result in better solutions and in greater commitment to the required actions, as well as improving the learning skills of the learner.

Listening

Attend to the speaker, listen and continue listening, letting the speaker see that you are doing so. Consciously avoid jumping to conclusions. Accept what is said, don’t dismiss explanations, and check your understanding at appropriate intervals. Allow thinking time before following up.

Managing

Use lubricators, “mmm”; inhibitors, “Yes, I’ve got that”; and bridges, “Let’s turn to…” to regulate the flow of information.

Using questions

General open questions about a topic followed by probing questions encourage people to express their opinions in some detail. If you want to further focus on an issue, hypothetical questions, “Would it help if you spent more time in cardiology?” or comparisons, “Would you prefer this or that?” are used. Closed questions establish matters of fact and can be used to confirm commitment to decisions.

Summarising

Paraphrasing what has just been said allows people to clarify and confirm points. Summarising the main points of a discussion allows it to move on or draws it to a conclusion. This ensures that both parties are clear about where they are, and it can also be used to establish commitment to any decisions. Asking the other person to provide the summary allows you to find out what they have taken from what has been said.

Giving information

Factual statements are used to provide people with information, “You are held to be responsible in this type of situation”. Evaluative statements communicate attitudes to events and offer criteria against which things can be judged, “It is better, in this type of situation, that the first doctor present takes charge until senior help arrives”. They can imply personal criticism, though (why didn’t you take charge?), and provoke a defensive response. Feedback gives people information about the effects of their actions, “Because no one was in overall charge, communication broke down and the critical information was not made available when needed”.

Non-Verbal Communication

Non-verbal communication is at work affecting your interactions. It pays to notice and understand non-verbal cues:

  • To monitor and understand how your behaviour, rather than your words, may be affecting a conversation.
  • The better to interpret the other person’s response.
  • To help you gather information and hold more effective meetings.

Non-verbal cues include facial expression, vocal characteristics, body posture and movement, people’s positions relative to each other, and the arrangement of artefacts – chairs, desks, papers or whatever. They express emotions, status and power, confidence, truthfulness. They regulate conversation.

Non-verbal communication is inherently ambiguous

Non-verbal behaviour varies between individuals, situations and cultures. For example, a lack of eye contact may imply a number of things including relative status, a need to concentrate on putting complex thoughts into words without visual distraction, or, depending on the culture, either respect or disrespect.

Some non-verbal cues are more reliable than others. A smile is usually associated with happiness, but even so, the smile may not be genuine.

Follow up non-verbal cues with questions

Despite their ambiguity, non-verbal cues are useful. They act as a warning that there may be something worth checking: you introduce what you believe to be a sensitive subject; the learner winces, turns away, and flushes slightly; “I get the impression that something I’ve said may have upset you”, “Not at all, I’ve just spilt my coffee”.

This exchange also illustrates the influence of preconceptions when interpreting other people’s behaviour. People tend to see what they want or expect, rather than what is really happening.

Non-verbal cues are used to regulate conversation

They tell the speaker to continue, repeat, elaborate, to let the other person say something… They tell the listener to pay special attention, to wait a minute before commenting, to confirm something, to respond at length… Misreading these sorts of cues can lead to a loss of information through interruptions, simultaneous speech or embarrassing silences. It can also cause frustration and resentment, particularly on behalf of those who feel that they have not had the chance to contribute.

Take care to notice the non-verbal cues of the other person

Not noticing can lead to ‘switching off by the other person, and to you not registering their true feelings on the matter in question. Non-verbal cues are often brief, and people usually mask their feelings to some extent. If you are busy planning your own contribution to the conversation and not attending with eyes and ears to theirs, or if when speaking you look away from the other person, you will not notice their reactions.

Be aware of the non-verbal signals that you are sending out

It is important to display appropriate non-verbal cues while speaking and listening. Inconsistency between verbal and non-verbal messages is likely to be interpreted as insincerity or deception, and it is the non-verbal messages that are more likely to be believed. A lack of non-verbal response deprives the learner of feedback from you. This may reflect that you are reserving judgement, but it may also cause the learner to dry up or feel resentment. Showing interest is as important as being interested.

Be aware of the effects of status

The effect of differences in status can either be minimised or emphasised through non¬verbal cues. It should be minimised when you are engaged in the participative processes of educational supervision. In other situations it may be appropriate to emphasise the difference. Seating arrangements, loudness and tone of voice, the amount of eye contact and interruption are all influential.

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