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ERS Annual Congress Vienna
15 September 2012

Postgraduate Course 20 European spirometry train-the-trainer programme


Saturday, 1 September 2012 08:4517:30 Room: C8

Motivating learning and providing effective feedback


Dr. Jamiu O. Busari Dept of Educational Development and Research Faculty of Health Medicine and Life Sciences Maastricht The Netherlands j.busari@atriummc.nl Aims
Acquaint participants with the concept of constructive feedback Highlight the importance of providing feedback effectively Describe how to provide feedback effectively after clinical presentations Examine the Pendleton rules as an effective method of feedback

Summary What is feedback?


Most people have an intrinsic need to know how well they perform at a task. Coupled to this, is an almost always expectation of success, which is fundamental to motivation and effort. Both tend to increase when an individual expects to succeed, but decrease (or cease) when the goal is perceived as almost certain or impossible [1]. Providing an individual with information on his or her performance during a task increases the chances of achieving success. The interaction that takes place (i.e. between the performer of a task and the observer) is aimed at reinforcing positive behaviour and providing specific guidelines to improve future performance. The interactive process is called feedback and is effective, only when the learner is offered insight into his or her actions and of the resultant consequences. Such insight is valuable as it highlights the difference between the intended and the actual result, and provides an impetus for change [2].

Why bother with feedback?


Feedback drives the learning process and is essential in allowing the leaner to remain on course in reaching his or her goal. It is welcomed when it is based on performance and tailored to the learning objectives [3]. When provided constructively, it produces significantly better learning outcomes in different learning situations (see table 1), deepens approach to learning and encourages active pursuit of understanding as well as application of knowledge [4, 5]. If handled improperly, feedback may damage the learner-tutor relationship and inhibit giving or receiving feedback in the future. In such situations, it is often viewed as a statement about personal worth or potential, whereas in reality its purpose is to present information and not judgement [6] (see table 2). The art of providing educationally sound feedback rests on the knowledge of a few principles (see table 3). To begin with, feedback is better received when the person receiving it is comfortable with the one providing it. Hence, a positive relationship between the person providing and the person receiving feedback facilitates the process. In the learning setting, it is also helpful to allow students to observe and comment on the performance of their teachers as this reminds both parties that learning is a two way process. As a rule, feedback should begin with positive comments, followed by an examination of issues that might be a concern, and rounded off with positive comments and suggestions for improvement. Overly negative feedback without any positive comment can appear harsh and intimidating. It should therefore be constructive, characterised by comments on what can be improved, rather than direct criticism. The focus should be on specific issues that can be clearly identified or described. Commenting that a persons body language was inappropriate during a presentation for example, is less helpful than commenting on eye contact, smiling instead of frowning, walking rather than standing still etc. Another important aspect of feedback is timeliness; as an

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observer, you want to provide feedback as soon as possible (e.g. following the observation) rather than several days later. Table 1. Advantages of effective feedback 1. Helps to clarify areas that need improvement for the learner (and teacher) 2. Prevents errors turning into habit 3. Provides learners with an accurate perception of own performance 4. Conveys an attitude of concern and interest between instructor and learner Table 2. Obstacles to feedback a. When feedback is based on goals different from that of the learner b. Perceived by the learner as personal judgment c. Inconsistent message is delivered d. Provided in an inappropriate environment e. Time constraints Table 3. General principles of feedback Give specific examples. Non-judgmental. Provide descriptive, rather than interpretive comments (Box 1) Focus on (modifiable) behaviour rather than interpretation (box 2) Language used should reflect observation rather than inference i.e. separate behaviour and interpretation (Box 2) Choose an appropriate time to provide feedback Provide feedback in a quantity that can be coped with Check that the provided feedback is understood Avoid collusion i.e. attempting to seek approval/agreement Make interpretations tentative Suggestive vs prescriptive Box 1. Difference between interpretive (judgmental) and descriptive (non-judgmental) language Interpretive or judgmental Descriptive or non-judgmental language language The beginning was awful, you just seemed to At the beginning you were looking at the notes, ignore her. which prevented eye contact Its no good getting embarrassed when patients I noticed you were very flushed when she spoke talk about their sexual history about her husbands impotence, and you lost eye contact Box 2. Examples of terms that describe behaviour and interpretation during feedback Behaviour Interpretation Bored Arms folded Good rapport Legs crossed Embarrassed Flushed cheeks Amused Rapid voice tempo Disgusted Slow steady breathing I saw you look at your watch and thought you might be bored I saw him talking with his hand over his mouth and wondered if he was lying

General guidelines for providing and receiving feedback after a (clinical) presentation
Generally, it is difficult for an individual to develop or improve his or her presentation skills without practising in a safe environment and receiving feedback on his or her performance. Ideally, when giving feedback, the presenter should be invited to comment on his or her performance before the observer does. It is better to ask presenters to comment on their own performance first as they are

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usually self-critical and are likely to raise issues that the observer has also identified. Helpful guidelines for providing and receiving feedback after (clinical) presentations are provided below.

Providing feedback
As the person providing feedback, ensure that you: Invite the presenter to speak first. It encourages the ability to critically appraise ones performance and self reflection Be specific with the comments you provide. A remark such as your presentation appeared chaotic is less helpful compared to the remark I was distracted when you appeared to lose track of your presentation and started searching for the correct slides Allow for a good balance of positive and negative feedback. An excess of positive feedback increases the chances of losing sight of opportunities for improvement, while an excess of negative feedback induces discouragement and loss of motivation. Direct feedback at behaviours that the presenter can improve. Providing critique on an individuals speech impairment for example, is not beneficial. Seek agreement with audience. Check if the content of your feedback agrees with the observations of other members of the audience and vice versa

Receiving feedback:
As the person receiving feedback, strive to: Listen to feedback without comments. You hear more when you concentrate on listening instead of attempting to defend your action and/or explain behaviour When necessary, ask for clarity when the person providing feedback is done. You should be certain that you understand the content and source of the provided feedback. Initiate own suggestions and actions for improvement. Explain clearly which specific actions you intend to take, what new ideas you would like to try out etc. Take notes. You can these later to reflect on the content and agreements made during the feedback discussion.

Pendletons Rules for constructive feedback


Pendletons Rules is a set of general principles used to provide structured feedback after performing different activities, e.g. practical skills, consultations and (case) presentations. It is a step-by-step model, where each step is important and should be carried out in a set order, described below [7]. Usually, the learner performs the activity first. Following observation of the activity, feedback is provided collectively by the group of observers or singly, by an appointed moderator (e.g. chairman, peer, or supervisor). The steps involved in this model are as follows: Step 1: Questions are allowed only on clarification of facts. Step 2: The learner then says what they thought was done well. Step 3: The moderator/group then says what they thought was done well. Step 4: The learner then says what was not done so well, and describes what could be improved upon. Step 5: The moderator/group then mentions what was not done so well and suggests ways for improvement, with discussion in a helpful and constructive manner. Pendletons rules is a useful model for providing feedback in formal situations, such as in the appraisal of recipients who are uncomfortable with feedback (e.g. individuals who are nervous), when recipients demonstrate a lack of insight of own performance and when the goal is to help learners recognize and acknowledge what is good about their performance. It is important to ensure that the comments provided through steps 25, do not exceed 3 in number and should also be SMART: 1. Specific - are clearly spelled out and detailed 2. Measurable - can be tested 3. Achievable - in terms of time and resources 4. Relevant - appropriate

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5. Timed - there is a defined time period in which to achieve them

Conclusion
Feedback is a generic skill that can be learned and when provided correctly, can improve learning outcomes and enable learners to develop an analytical approach to learning. The best way to learn how to give effective feedback is to practice. A structured feedback model may feel artificial and unhelpful until the technique has been mastered and developed into familiar vocabulary and/or series of phrases to help. However when mastered, it can be effectively used in settings such as formal educational supervision, clinical presentations as well as in day-to-day situations with colleagues, staff and patients. Ultimately, feedback is about communication; the key skills are to listen and ask, not to tell and provide solutions [1].

References
1. King J. (1999) Giving Feedback. BMJ 318:2. 2. Nadler DA. (1977) Feedback and Organisation Development: Using Data-based Methods. Reading, MA: Addison-Wesley. 3. Knowles MS. (1980) The Modern Practice of Adult Education: From Pedagogy to Andragogy. 2nd ed. Chicago: Follet Publishing Co. 4. Black P and William D (1998) Assessment and classroom teaching. Assessment in Education 5:7-73. 5. Rolfe I and McPherson J (1995) Formative assessment: How am I doing? Lancet 345:837-9. 6. Hyman RT. (1980) Improving Discussion Leadership. New York: Teachers College Press. 7. Pendleton D, Schofield T, Tate P, Havelock P. (2003) The New Consultation. Oxford University press, ISBN 0-19-263288

Additional reading
1. Teaching made easy, Chambers and Wall, Radcliffe 2000, ISBN: 1-85775-373-9 2. Teaching and learning communication skills in medicine, Kurtz, Silverman and Draper, Radcliffe 1998, ISBN: 1-85775-2723. Adult and continuing education, Jarvis, Routledge 1995, ISBN: 0-415-10242-1 4. Pendleton D, Schofield T, Tate P, Havelock P. The Consultation: An Approach to Learning and Teaching. Oxford: Oxford University Press; 1984.

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MOTIVATING LEARNING AND PROVIDING EFFECTIVE FEEDBACK


Dr. Jamiu O. Busari MD, MHPE, PHD Dept. of Pediatrics, Atrium Medical Center/University of Maastricht, Educational development & research dept.

MOTIVATING LEARNING

PRINCIPLES OF ADULT LEARNING

Adult learners are motivated by intrinsic factors and more likely to learn when: Instruction is problem centered Is in a supportive environment Learning is experience orientated Learning is active versus passive Effective feedback is provided

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1. PROBLEM CENTERED INSTRUCTION


Emphasizes learning of concepts not just facts Provides opportunity for practicing problem-solving skills TIPS Think aloud as you reason out problems and management Pose case problems Make full use of the teachable moment

2. SUPPORTIVE ENVIRONMENT
Non-threatening/non-judgmental environment Mutual trust and respect Encourages self-confidence and initiative TIPS Introduce yourself and learn names Be available and approachable Respond constructively to problems or questions

3. EXPERIENCE ORIENTATED INSTRUCTION


Links information being taught to real life Advances learners through stages of skill acquisition & reinforces learning TIPS
When teaching a procedure: Demonstrate it Explain each step Provide supervised practice Give feedback

AND be patient

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4. ACTIVE LEARNERS
Learners more motivated to learn
Attention is maintained Retention is enhanced

Engage in critical thinking and inquiry TIPS


Encourage participation: brainstorming, role-playing, demonstrating, questioning Use open ended questions to promote critical thinking Give learners time to think and respond Relate new information to previous knowledge

5. PROVIDING EFFECTIVE FEEDBACK

...what ? ...why ? ...who ? ..when ? ..how?

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FEEDBACK WHAT?

Interactive process aimed at reinforcing positive behavior and providing specific guidelines for the future

FEEDBACK WHAT?

Feedback is a communication skill

Communication skills are neither intrinsically good nor bad, they are just helpful, or not helpful, in achieving a particular objective in a given situation (Silverman et al., 1998)

FEEDBACK
Causes change in (certain) behaviours

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FEEDBACK WHY?

Insight in performance Reinforcement (success breeds success) Better understanding and application of knowledge

FEEDBACK WHO?
Goodmentor Friend Patient Respectful

Busarietal.,2005

Bearinmind: Showinterestintheindividual Stayuptodate

FEEDBACK WHEN?

Direct(assoonaspossible)

Calmmoment

Scheduleanappropriatemoment

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FEEDBACK HOW?
TYPE

formal feedback informal feedback

Hownot: feedbackasacomplicationreviewsession!

FORMAL FEEDBACK
THINGS TO KNOW

Plan ahead (prospective) Views should be personal Give specific examples Appropriate timing Focus on modifiable behaviour Descriptive (non-judgmental) comments Encounter resistance: stop and listen Concise & clear Balance positive and negative comments

OBSTACLES TO EFFECTIVE FEEDBACK


- Perceived as personal judgment - Inconsistent messages - Inappropriate environment - Time constraints - Focused on goals different than those of the learner

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FORMAL FEEDBACK HOW?


PENDLETONS RULES

How did it go What went well

- General perception - Presenters perception - Observers perception

What can be improved - Presenters perception - Observers perception Summarize - Positive points - Points for improvement

GUIDELINES FOR PROVIDING FEEDBACK


When providing feedback ensure that you:

Invite the presenter to speak first. Be specific with your comments. Balance positive and negative feedback. Direct feedback at improvable behaviour. Seek agreement with audience.

GUIDELINES FOR RECEIVING FEEDBACK


When receiving feedback strive to: Listen without commenting When necessary, ask for clarity Initiate own suggestion/actions for improvement. Take notes.

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WRAPUP.

FEEDBACK GUIDELINES

Timing Environment Appropriate Manageable

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