Karen K. Cornell
College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, USA
The term feedback was utilized first in the 1860s industrial revolution to describe the process by which output signals of energy, or momentum, are returned to the point of origin within a system to modulate future performance of that system. In these systems, the returning signal immediately influenced future output. Review of this original use of the term is valuable to remind one of the ultimate goal of feedback, which is to influence future performance. A critical difference between feedback in medical education from that within a mechanical system is the human influence on the process. The characteristics of the provider of feedback, the individual receiving the feedback, and the culture or environment within which the feedback is given greatly affect the ability of feedback to influence future performance. An additional objective of feedback in medical education is again related to the human portion of the feedback process, and is the reinforcement of feedback-seeking behavior. Feedback- seeking, defined as the conscious devotion of effort toward determining the correctness and adequacy of one’s behaviors for attaining valued goals, facilitates the lifelong learning required of veterinarians (Ashford, 1986).
There are many important dimensions within the definition of feedback. The components of effective feedback in medical education include provision of information regarding prior performance, promotion of positive and desirable learner development, resultant action taken by the learner, facilitation of refinement of the learner’s self-assessment skills, and promotion of future feedback-seeking. It is important to differentiate between feedback and evaluation. Feedback is intended to be instructional, providing information for the learner regarding the gap between current performance and desired performance, and is forward looking, specific, and descriptive. Feedback is not always corrective, and may be employed to reaffirm performance that requires no modification, using specific examples for clear illustration. In contrast, evaluation is focused on the past and is a judgment of past performance. While some evaluations include feedback, the simple attainment of a “B+” gives a learner little information regarding how to improve their knowledge or application of knowledge. Winne and Butler (1994, p. 5740) defined feedback as “information with which a learner can confirm, add to, overwrite, tune, or restructure information in memory, whether that information is domain knowledge, meta-cognitive knowledge, beliefs about self and tasks, or cognitive tactics and strategies.” A key point is that this definition includes the need for learner self-assessment, and it requires the learner to confirm the accuracy of feedback received, or tune it to their own beliefs. In addition to addressing a specific task or act, this process aids in the development of the learner’s self-assessment skills (see Box 17.2).
There are many common assumptions regarding feedback. These include that all feedback is good feedback, more feedback is better, feedback is a one-way flow of information, feedback is complete when the message is delivered, and one model of feedback is effective for all learners and all situations. It is important for veterinary medical educators to move beyond these assumptions. The goal of this chapter is to provide the background information and scaffolding to assist in making that move.
Hattie, Biggs, and Purdie (1996) report that the influence of feedback on student achievement is highest in situations in which the student has demonstrated prior cognitive ability; direct instruction was provided; there was reciprocal teaching; or direct feedback was offered. While the impact of feedback varies, the greatest demonstrated effect was reported when feedback was provided regarding a specific task and how to perform that task more effectively. Multiple studies in medical education have demonstrated that individuals in an environment with feedback have greater confidence and motivation, interpersonal skills, learner satisfaction, clinical performance, accuracy of self-assessment, and patient satisfaction (see Box 17.3; Crommelinck and Anseel, 2013; Boud and Molloy, 2013; Thomas and Arnold, 2011; Clynes and Raftery, 2008; Davis et al., 2006). Conversely, individuals who do not receive feedback are more likely to overestimate their abilities, lack reinforcement of effective performance, fail to correct poor performance, and receive a false positive impression (Davis et al., 2006; Ende, Pomerantz, and Erickson, 1995; Laidlaw et al., 2006; Waitzkin, 1985; Spickard et al., 2008; Cantillon and Sargeant, 2008).
Numerous studies have been done to assess the effect of the timing of feedback as it relates to academic achievement. Results vary and are challenging to quantify. There are many factors related to timing that influence the effectiveness of feedback, including the difficulty or complexity of the task and the amount of processing required to complete it (Schroth, 1992). Delayed feedback may be better for supporting the transfer of knowledge, whereas immediate feedback may be more effective in the short term for supporting the development of procedural skills (Schroth, 1992).
Positive or Negative Feedback
Whether feedback is reinforcing or corrective in nature may influence its impact on the learner’s ability to enact change. In some instances overly critical feedback can have a negative impact on learning (Kluger and DeNisi, 1996; Hattie and Timperley, 2007).
On average, positive and negative feedback are similar in their effects on performance, but it is well documented that feedback that threatens the self is likely to debilitate recipients (Kluger and van Dijk, 2010; Sargeant et al., 2008). For this reason, feedback is best received and acted on if the learner’s preferences regarding feedback are considered. Because the individual receiving the feedback must be able to decode and utilize the information provided, it must be considered that each learner brings to the interaction their own thoughts, experiences, and self-assessments. In situations in which the learner seeks feedback, it is important to consider the types or features of the feedback that they are seeking. Some learners seek appreciation in order to gain motivation and encouragement, some seek coaching so that they may move their own performance closer to the desired performance, and others truly seek evaluation so that they know their location relative to the standards or performance of others. This desire for evaluation also facilitates the alignment of their expectations and informs their decision-making (see Box 17.4; Stone and Heen, 2014).
Archer (2010, p. 101) states that “educators must acknowledge the psychosocial needs of the recipients while ensuring that feedback is both honest and accurate.”
Promotion or Prevention Focus
Kluger and van Dijk’s 2010 study suggests that the benefit of positive or negative feedback is dependent on the regulatory focus of the learner: promotion or prevention (see Box 17.5). Learners, and the tasks with which they are confronted, may be prevention or promotion focused (Watling et al., 2012). A prevention focus indicates that all actions are directed toward avoiding poor outcomes or punishment, and as a result learners do things because they perceive they must do them. For instance, completing a calculation for a constant-rate infusion might be considered a prevention-focused task, since the penalty for failure or error is very high. In this example, achieving the correct answer is met with relief and is not likely to change performance in the future, while a negative outcome is likely to change future performance drastically. A promotion focus indicates that actions are directed toward the achievement of reward or pleasure, thus it involves goals that are desires and things the learner wants to do. An example of a promotion-focused task might be the assignment to develop innovative ways to distribute personnel in order to cover work shifts. If the feedback regarding the innovative plans includes the comment that they are appropriate, effective, and helpful, the learner is likely to be motivated to contribute more. If, however, the ideas are received negatively, the learner may be inclined to abandon attempts to improve. In healthcare, promotion and prevention foci become complicated to differentiate. As veterinary healthcare professionals we are required to be aware of potential mistakes and their impact, for instance the failure of a ligature resulting in hemorrhage, while also thinking “outside of the box” in diagnosis and treatment, for example performing a muscle biopsy for an unusual weakness presentation (Kluger and van Dijk, 2010).
Learners’ perception of feedback is also important to understand. In a study of medical students, 96% considered it important to receive feedback, yet only 59% felt that they received enough feedback (Murdoch-Eaton and Sargeant, 2012). Perhaps the most disturbing finding of this study was that only 36% of students reported that they knew where to seek additional feedback. This lack of knowledge of where to seek feedback is counterintuitive, since these were students in training programs; it seems they should have known to ask their teachers. Perhaps this has more to do with the features of the possible providers of feedback than a true lack of knowledge of where to seek it.
Another key feature of the learner is an understanding of where they are in the learning process for the task in question. Eva et al. (2012) report a paradox in student response to feedback, with the finding that individuals need to achieve a level of comfort, experience, and confidence prior to being prepared to ask for or receive corrective feedback. In practice, this means that we must give the student time and space to make attempts at a task or behavior before providing immediate feedback. For example, immediately correcting the student’s grip of needleholders before they begin suturing for the first time is likely to frustrate them more and result in less long-term impact than allowing them to recognize the difficulties of utilizing the incorrect grip and then providing suggestions for improvement.
As mentioned earlier, medical students desire feedback and do not believe that they receive enough feedback (Murdoch-Eaton, 2012). Why do they not ask? Studies in human and veterinary medical education indicate that students, and residents for that matter, are reluctant to seek feedback (Eva et al., 2012; Bok et al., 2013; Delva et al., 2013; Reddy et al., 2015). Encouragement of feedback-seeking, or “the conscious devotion of effort towards determining the correctness and adequacy of one’s behaviors for attaining valued goals” as defined by Ashford (1986, p. 466), requires that several characteristics of a feedback provider are met.
Based on a study by Crommelinck and Anseel (2013), characteristics of the feedback provider that influence feedback-seeking behavior are the history of a provider already giving feedback to the learner, the accessibility of the feedback provider to the learner, and the perceived level of expertise associated with the provider as it relates to the task at hand. In a separate study of faculty and residents in human medicine, Delva et al. (2013) reported that the lack of quality of the feedback provided, the lack of direct observation, and the provision of infrequent feedback were factors that discouraged feedback-seeking by residents in training. Bok et al. (2013) reported that veterinary students sought feedback more when they perceived that the feedback provider had good communication skills, the provider could give feedback on directly observed learner performance, and there was a longer history of working together. The duration of time working together was also reported as an important factor in feedback behaviors by both faculty and residents in Delva et al.’s (2013) study. Feedback is best received, and therefore acted on, when it is perceived as being provided from a position of beneficence by an individual with whom the learner has developed a relationship of respect during the experience (Watling et al., 2012; Boud and Molloy, 2013). The characteristics of feedback providers that promote feedback-seeking behaviors are included in Box 17.6.