Feedback and the learning process
It is very important to ensure that the feedback given to the learner is aligned with the overall learning outcomes of the programme, teaching session or clinical activity in which the learner is engaged. Giving feedback is part of experiential learning which, for health professionals, involves ‘learning on the job’ and purposefully reflecting on situations, feelings and various experiences.
Kolb (1984) proposed that learning happens in a circular fashion, that learning is experiential (learning by doing), and that ideas are formed and modified through experiences. These ideas underpin the idea of the ‘reflective practitioner’ and the shift from ‘novice to expert’ which occurs as part of professional development.
The learning cycle requires four kinds of abilities or learning contexts:
- Concrete Experience – learners are enabled and encouraged to become involved in new experiences (‘ok, you have watched me manipulate a shoulder a number of times, now I’ll watch you do it with the next patient’)
- Reflective Observation – gives learners time to reflect on their learning (‘how do you think that went? Could you feel the resistance there...what might you do next time, more of, less of.....’)
- Abstract Conceptualisation – learners must be able to form and process ideas and integrate them into logical theories (‘let’s think about the anatomy again, describe the joint structure to me .... how does what you were feeling and doing relate to the anatomy?’)
- Active Experimentation – learners need to be able to use theories to solve problems and test theories in new situations (‘the next patient has a frozen shoulder; how do you think you’ll approach this one in relation to the previous patient and your learning?’).
Remember, the learning might start at any point in the cycle - you might review the anatomy and rehearse the steps in the procedure with the learner before they see the patient.
This cycle is similar to the ‘plan – do – reflect – review’ cycle which is often used in appraisals. It is important to note that the points in these cycles are not necessarily sequential and that in practice one or more activities may be occurring at the same time. However, feedback at various points is very important in helping learners develop competence e.g. feedback supports the process of reflection and the consideration of new or more in-depth theory and can also help the learner plan productively for the next learning experience.
If we consider that one of the tasks of those giving feedback is to help the learner achieve their learning goals, then Hill (2007) suggests that we need to start with an understanding of:
(a) where the learner is in terms of their learning, the level they have reached, past experience, and understanding of learning needs and goals (this is a 3rd year medical student who is on their first medical ward, very different from a final year student who is qualifying in three weeks’ time)
(b) the learning goals in terms of knowledge, technical skills and behaviours. You may be observing more than one of these learning domains at the same time (‘I’d like you to carry out the pre-operative checklist on the next patient, I’ll watch how you do it and particularly focus on how you give her accurate information and reassurance about the operation’).
During the observation, our task is to identify where and how far the learner has travelled towards the learning goals, where they may have gone off track and what further learning or practice may be required.