March 2010, Volume 60, Issue 3

Review Articles

Understanding constructive feedback: A commitment between teachers and students for academic and professional development

Yasir Hamid  ( Centre for Medical Education, University of Dundee, Scotland, UK )
Sajid Mahmood  ( Department of Community Health Sciences, Aga Khan University, Stadium Road, Karachi, Pakistan. )

Abstract

This review highlights the need in the Pakistani medical education system for teachers and students to be able to: define constructive feedback; provide constructive feedback; identify standards for constructive feedback; identify a suitable model for the provision of constructive feedback and evaluate the use of constructive feedback. For the purpose of literature review we had defined the key word glossary as: feedback, constructive feedback, teaching constructive feedback, models for feedback, models for constructive feedback and giving and receiving feedback. The data bases for the search include: Medline (EBSCO), Web of Knowledge, SCOPUS, TRIP, ScienceDirect, Pubmed, UK Pubmed Central, ZETOC, University of Dundee Library catalogue, SCIRUS (Elsevier) and Google Scholar.
This article states that the Pakistani medical schools do not reflect on or use the benefits of the constructive feedback process. The discussion about constructive feedback suggests that in the context of Pakistan, constructive feedback will facilitate the teaching and learning activities.

Introduction

In Pakistani medical schools, we usually do not provide our students with feedback which may be restricting the academic development of students as well as the professional development of tutors. In some situations we consider 'awarded marks' as a sufficient feedback for our students. Moreover, in cases where awarded marks are acting as a feedback, such medical schools may need to work on standards for the provision of constructive feedback.
The students may have no idea about their progress (in the absence of feedback) or may have a false idea about their progress (in case of unplanned or insufficient feedback). The insufficient feedback focuses on situations where awarded marks are provided as a feedback.
The introduction of "Constructive Feedback" for tutors may subsequently enable the tutors to provide their students with well planned, skilful, and useful constructive feedback for the academic development of their students and for their own professional development. The developmental attribute of constructive feedback is expressed as:
"Constructive feedback is a powerful instrument and facilitates the learner's professional and personal development."1
What is feedback?
Various authors highlight factors that constitute the definition of feedback. It was defined as:
"The definition of feedback in organizations and business is ongoing, open two-way communication between two or more parties."2
Another contribution was put forward, that:
"Based on Ende's principles, feedback should be descriptive and non-judgemental."3
Similarly, in line with the definition above, through the investigation of effective verbal feedback in graphic design critiques, highlighted that the strength in the planning of feedback is that it should:
"Appreciate good things."4
Other researchers feel that:
"Where there are agreed standards of behaviour and performance, and two-way communication about what has gone right as well as what has gone wrong, there is feedback we define as constructive feedback."5
Thus, we can define feedback as a process which involves a two way non judgemental communication with the purpose providing information about quality of work to enhance ones ability. It has two main objectives:

  • to appreciate the good/right things with logical explanations
  • identify the bad/wrong things and provide options to change them.

In the context of medical education, the two way communication usually takes place between tutors (preceptors) and students (performers).
The significance of feedback has been justified as:
"Feedback is an essential activity for helping trainees (students) reach their maximum potential at their particular stage of training."6
In the context of medical education, feedback communication usually takes place between the tutor and the student. The teacher's perspective about feedback is:
"Teachers also seek feedback as a means to acknowledge effective teaching practices, to identify areas of need and to provide suggestions for improvement."7
Feedback vs Constructive Feedback:
The process of feedback can be negative or positive but the important thing is that it should be constructive and not destructive in nature.
Constructive feedback can be used as a tool for high-quality learning and that in situations of incongruity between the actual and desired performances, the process of feedback may act a useful tool for students' growth and academic development. The investigators state that:
"Medical students and residents are willing to get and need constructive feedback and they clearly associate it to high-quality learning."8
Moreover, it was emphasised that:
"Constructive feedback increases self awareness, offers options and encourages development."9
In addition to the advantages above, and based on its principles constructive feedback has many teaching and learning benefits. There are 8 steps highlighted as the beneficial aspects from the learning point of view and 6 steps are described as the advantageous aspects of constructive feedback regarding teaching.7 We will discuss these advantages in the following section of "feedback for teaching and learning".
Principles, Characteristics of Guidelines for constructive feedback:
The process of constructive feedback works on the basis of number of characteristics. In many studies these characteristics are given the label of principles of constructive feedback and in some studies these are labelled as guidelines for constructive feedback. No matter what the label, the process should run on the characteristics highlighted by the literature review in the discussion below.
As stated earlier, the process of feedback can be negative or positive but it should be constructive and not destructive in nature. In contrast to destructive feedback, constructive feedback has advantages that it helps in solving the problems without offending the other person, changes behaviour towards positivity, encourages and supports development, suggests corrective measures, provides meaningful direction on the basis of logic and has the potential to turn criticism into something constructive.
The constructiveness of a feedback activity was supported as:
"Feedback can either be positive-reinforcing 'good' performance and behaviours-or negative-correcting and improving 'poor' performance and behaviours. Both type of feedback can and must be constructive."10
Constructive feedback must also posses features like being descriptive; timely; honest; useful; respectful; clear; issue specific; supportive; motivating; action oriented; solution oriented; strictly confidential; trust; collaborative and informative.
The features of the activity are further clarified:
"Feedback should be phrased in descriptive non evaluative language; feedback should be well timed and expected. Feedback should deal with specific performances, not generalisations; feedback should deal with decisions and actions, rather than assumed intentions or interpretations; feedback should be undertaken with the teacher and trainee working as allies, with common goals."11
Although the identified features are more or less similar many authors classify them as principles, characteristics, and guidelines. They categorize and group them as: ten principles (12); seven principles (13); seven principles (14); characteristics of feedback (7); guidelines for constructive feedback (11) and guidelines for feedback (15).
Standards of Constructive Feedback:
In this section we propose the key features of constructive feedback that can be used as 14 standards for feedback. The list below has been developed after careful scrutiny of the principles, guidelines and characteristics of good feedback practice in the studies reviewed. The standards for a constructive feedback for medical students and teachers should be:

  •  well timed and expected (as early as possible and agreed between participants for their common goal/s)
  •  based on first hand data (without any intermediate source and through direct observation)
  •  confidential (to maintain trust and respect)
  •  quantity regulated (reasonable amount of information)
  •  balanced (appreciation for good things and suggestions for improvement)
  •  clear (in terms of goals, criterion and standards)
  •  encouraging (for time, effort, positive believes i.e. encouragement for whatever is right or good, interaction and dialogues with peer and teacher)
  •  helpful (for teaching and learning activities i.e. helpful in improving teaching and for achieving common academic goals)
  •  opportunistic (with opportunities for raising current performance to meet standard performance)
  •  purposeful (to plan a strategy, to improve results, to clarify standards, etc.)
  •  relevant and tailored (according to needs and interest of an individual)
  •  factual (based on actual performance rather than assumptions or interpretations)
  •  descriptive (non-evaluative)
  •  specific (focusing the observed and changeable behaviour).
  • Feedback for Teaching and Learning:

Constructive feedback has many teaching and learning advantages which were highlighted by Ovando.7 These advantages are based on the principles of constructive feedback and fundamentally show the benefits of the principles involved in the process of constructive feedback. There are 6 steps of constructive feedback that are beneficial from the teaching point of view and 8 steps that are advantageous for learning.7
The 6 steps that facilitate feedback for teaching include: set a climate for trust and respect; clarify expectations of performance; gather significant information from students and others, i.e. ask questions about the class, request written comments, place a suggestion box in a convenient location in the classroom, etc.; review each comment or piece of information and acknowledge it; adjusting teaching as needed by introducing pertinent modifications or using new strategies; evaluate effectiveness of modifications.
In constructive feedback, the 8 steps involved in a learning activity are described as follows: provide clear expectations about student learning and performance; explain specific criteria to judge students' achievements; collect pertinent information about student progress; acknowledge accomplishments and students' progress; identify areas which need further study or additional practice; recognise students' efforts towards achievements of goals and objectives; suggest learning activities, learning tools and study techniques for additional study; encourage students to increase efforts.
Giving and Receiving Feedback:
Giving and receiving feedback is another important factor in the process of constructive feedback. Studies show that the students feel that they should be provided with constructive feedback which they find helpful in their academic activities. We often see however, that the students do not request feedback on their own. Therefore, if the tutors give feedback to their students, it is expected that the students will receive it and together both the students and tutors can help each other in improving students' performance and stimulating tutors' professional development.
The relevant approach was expressed as:
"Medical students and residents are willing to get and need constructive feedback and they clearly associate it to high-quality learning."8
Tutors should take advantage of the students' willingness to accept feedback and should provide them with effective feedback. This provision should follow the standards of feedback and must be rich in the characteristics of constructive feedback. The significance of giving constructive feedback is evident from the approach put forward by Alves de Lima.8
"It is essential to take maximum advantage of feedback by giving recommendations, producing reactions and self-analysis and also by defining appropriate action plan."
Therefore, both giving and receiving feedback are of vital importance for the implementation of constructive feedback.
Models for Practising Feedback:
There are many models developed and implemented for providing constructive feedback.
The basic aim of these models is to deliver constructive feedback by focusing on the principles and features involved in the process of feedback. The most commonly used models include, Pendleton's rules; Giving Feedback Checklist; T.E.L.L. Model; SIPP Model; W3 Model; SLC [Success, Learn, Change] Model; Sandwich Model; THANCS Model and BOOST Model.16,17
Here we will focus on the TELL model for constructive feedback. We have chosen this model because of its simplicity and ability to address all the characteristics of constructive feedback including the most important aspect of feedback - that it is two way communication.
TELL Model:
This model is a very good example of creating an environment in which the process of constructive feedback can take place as a real two-way communication process with ability to discuss the issues in descriptive form along with their solutions. This model has the following features:

  •  "TELL them, specifically, about the exact behaviour you want repeated or is problematic (and therefore, to be corrected). Be objective and beware of taking a position about your observations.
  •  EXPLAIN what results or implications are created by their actions either negative or positive. Do not blame or attack
  •  LISTEN to their ideas for correcting the problem. Solicit their "buy-in" and be prepared to negotiate to an agreeable solution.
  •  LET them know what positive or negative consequences will occur if the problem is corrected or not. Indicate payoffs, penalties, rewards or punishments for accepting or rejecting the solutions for change. Avoid threatening or making commitments you can not fulfil".

Other models have different issues for their utilization. For example, Pendleton's rule has a rigid formulation; SIPP and SLC are the models for training in situations where feedback is in practice but it acts as criticism rather than constructive feedback; THANCS, BOOST and Checklist models focus on specific characteristics of constructive feedback; the Sandwich model cover all the characteristics of the constructive feedback process but does not address the two-way communication aspect.

Methodology

For the purpose of literature review the key word glossary used was: feedback, constructive feedback, teaching constructive feedback, models for feedback, models for constructive feedback and giving & receiving feedback. The data bases for the search include: Medline (EBSCO), Web of Knowledge, SCOPUS, TRIP, ScienceDirect, Pubmed, UK Pubmed Central, ZETOC, University of Dundee Library catalogue, SCIRUS (Elsevier) and Google Scholar.

Conclusion and Recommendations

In general the medical schools of Pakistan are deficient in concept of a feedback process and its significance; the teaching and learning activities lack the benefits of this constructive process. The discussion about constructive feedback suggests that for medical students and tutors in the context of Pakistan, will facilitate teaching and learning.
Through constructive feedback awareness, learning will be facilitated by collecting information about students, by identifying the areas for further study or requiring additional practice, by encouraging students to increase their efforts and by suggesting different learning activities, tools, and study techniques.

References

1.Bhattarai M. ABCDEFG IS - the principle of constructive feedback. JNMA J Nepal Med Assoc 2007; 46: 151-6.
2.Wilhelm L. Characteristics of Good Constructive Feedback 2008. [Online] [Cited 2008]. Available from URL: http://www.articlesbase.com/communication-articles/characteristics-of-good-constructive-feedback-445867.html.
3.Chowdhury R, Kalu G. Learning to Give Feedback in Medical Education. Obstet Gynaecol 2004; 6: 243-7.
4.Taylor M, McCormack C. Juggling Cats: Investigating Effective Verbal Feedback in Graphic Design Critiques. The Australian Council of University Art and Design School annual conference, 2004.
5.Roland, Frances B. Constructive feedback. Management shapers; 1996.
6.Hesketh EA, Laidlaw JM. Developing the teaching instinct. Med Teach 2002; 24: 239-40.
7.Ovando MN. Constructive feedback: A key to successful teaching and learning. Int J Educ Management 1994; 8: 19-22.
8.Alves de Lima AE. [Constructive feedback. A strategy to enhance learning]. Medicina (B Aires) 2008; 68: 88-92.
9.Centre for learning and teaching UoS. Principles of constructive feedback 2003. [Online]. Available from URL: www.clt.soton.ac.uk/Events/Workshops/OPS/feedback.htm.
10.Roland, Frances B. Constructive feedback. Management shapers; 1996.
11.Ende J. Feedback in clinical medical education. JAMA 1983; 250: 777-81.
12.Nicol D. Principles of good asssessment and feedback: theory and practice. [Online] 2006. Available from URL: http://www.reap.ac.uk/public/Papers/Principles_of_good_assessment_and_feedback.pdf.
13.Draper S. A momentary review of assessment principles. [Online] 2007. Available from URL: http://www.reap.ac.uk/reap07/Portals/2/CSL/keynotes/ david%20nicol/A_momentary_review_of_assessment_principles.pdf.
14.Minnesota Department of Health. The seven principles of feedback. [Online] 2006. Available from URL: http://www.health.state.mn.us/about/strategic/feedback.html.
15.Nicholson S, Cook V, Naish J, Boursicot K. Feedback: its importance in developing medical students\' clinical practice. The clinical teacher 2008; 5: 163-6.
16.Natural Assets. Three Feedback Models. [Online] 2006. Available from URL: http://www.naturalassets.org.uk/3waystofeedback.pdf.
17.Taylor MA. Interpersonal Communication skills. [Online] 2003. Available from URL: http://www.gym.net/?searchFor=feedback.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: