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Clinical pharmacy education
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Feedback in clinical pharmacy education Brian Grover, Bryan D. Hayes, and Kristin Watson Am J Health-Syst Pharm. 2014; 71:1592-6
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eedback has been identified as one of the crucial components of clinical training programs.1,2 Specifically within pharmacy education, feedback to improve clinical judgment is noted as one of the main purposes of residency training.3 However, the bulk of feedback literature pertains to other disciplines (e.g., medicine) and, although many of the principles are similar, perspectives on feedback principles as they relate to pharmacy trainees are needed. Even when preceptors feel certain they are providing feedback to trainees, there is some disagreement as to whether that feedback is being received.2,4 Given the importance attributed to feedback for improving clinical competence, the identification of key steps in providing effective feedback seems vital to preceptorship. We have drawn on personal experience and identified several key articles to define effective feedback and present an avenue for providing effective feedback in the clinical pharmacy setting. In addition, we present several pitfalls and challenges that can hinder effective feedback and then offer strategies to overcome them.
What is feedback and why is it necessary? Feedback is the provision of information for the purpose of evaluating or correcting behavior. The Accreditation Council for Pharmacy Education (ACPE) requires a qualityassurance process for all pharmacy practice experiences. This includes a process to provide feedback and to ensure interrater reliability when students’ performances are assessed. Additionally, the ACPE guidelines require that the associated outcomes of the pharmacy practice experiences be documented and assessed and that students have contact with a preceptor to ensure that feedback is received.5 Feedback is also an essential component of residency training and is mandated by several principles in the accreditation standards of the American Society of Health-System Pharmacists (ASHP).3 In fact, for postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) training, the ASHP standards require feedback for both residents and preceptors. Improvement of the feedback process is vital for continued growth of the resident and the training program.3 From a clinical perspective,
Brian Grover, Pharm.D., BCPS, is Clinical Specialist, Internal Medicine and Antithrombosis; and B ryan D. H ayes , P harm .D., DABAT, is Clinical Specialist, Emergency Medicine and Toxicology, University of Maryland Medical Center, Baltimore. Kristin Watson, Pharm.D., BCPS (AQ-Cardiology), is Associate Professor and Residency and Fellowship Program Coordinator, University of Maryland School of Pharmacy, Baltimore.
Address correspondence to Dr. Hayes ([email protected]). The authors have declared no potential conflicts of interest.
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Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/0902-1592. DOI 10.2146/ajhp130701
Am J Health-Syst Pharm—Vol 71 Sep 15, 2014
feedback has long been noted to play a significant role in the training of clinicians, and the difficulty of providing feedback in an effective manner is well recognized.2,6 Therefore, identifying and disseminating key strategies for ensuring a positive feedback session should improve the overall clinical skills of trainees. The principles described in this article apply to interactions with both pharmacy students and residents. Feedback versus evaluation. The terms feedback and evaluation are often used interchangeably, but actually they are unique entities. The primary difference between feedback and evaluation is the ultimate intent, though from a learner’s perspective they might initially seem the same. The goals of both are (1) to provide information to trainees with the intention of narrowing the gap between actual and desired performance, (2) to encourage learners to think about their performance and how they might improve, and (3) to effect changes in the learner’s thinking, behavior, and performance. 1 Feedback should be used to provide information on actions that were directly observed and the effect of those actions. Evaluation is intended to judge a performance or achievement of a goal, generally at the end of an activity.6 Both feedback and evaluation should enable the trainee to repeat positive behaviors or improve performance when similar situations are encountered in the future. In essence, feedback and evaluation must always be focused on the goal of improvement. This similar purpose might contribute to some of the confusion regarding these terms. A consequence of the ambiguity of these terms is that confusion can lead
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a trainee to misunderstand the intent of feedback or assume that it did not occur. Thus, improving the format and effectiveness of feedback will be useful for everyone involved in training pharmacy students and residents. Setup for success. Guidelines for delivering feedback have been described in the literature for medical education and training in clinical settings.2,6 In general, they discuss appropriate timing and working in concert with the trainee to see that feedback is not a judgment but a tool to help him or her improve. Additionally, feedback should be based on observed findings. It should avoid evaluative statements, be specific, and address decisions or actions rather than intentions or assumptions. The first step toward avoiding confusion about feedback is to set expectations. Without taking the time to describe what goals are to be learned, to express preferences regarding communication style and timing, to delineate requirements for follow-up, and to agree on a format to be followed or specific information to be discussed, the preceptor introduces a setup for potential “failure” in the resident’s mind and possibly for barriers to positive interactions in the future. Once the expectations are explained, it is more likely that feedback will be framed from a place of mutual understanding. To improve dissemination of expectations, one option is to provide the learner with an in-depth description of the rotation. This resource describes, in detail, the goals for the rotation and the activities used throughout the rotation to accomplish them. Each activity might have its own goals, and each activity should contribute to the overall goals of the rotation. Students and residents should also be asked to provide three or four personal goals for the rotation. Setting such goals early on helps create expectations that are clear to both the teacher and
the learner, thereby ensuring that feedback is aligned with a shared understanding of the objectives. Feedback must be provided in the appropriate setting. The idea of feedback is to provide timely commentary on how a particular task or decision was performed; sometimes, it should be provided immediately. Feedback is generally most effective when given soon after a task, particularly if patient care will be affected, but sensitivity to the setting is also necessary. The trainee should be taken aside if the situation poses the potential for embarrassment. Feedback also can be provided in a group setting, particularly when multilevel groups of trainees (e.g., students and residents) are involved, as this approach can facilitate learning and minimize the need to repeat the same concept multiple times. It can be useful to have the trainee formulate a self-assessment before hearing feedback from the preceptor. This process can be initiated by asking the resident to describe how well the activity was performed from his or her perspective, including strengths and areas for improvement. Self-assessment can clarify goals, identify dissonance between expectations, and align the feedback to make certain everyone is “on the same page.” Ultimately, the goal is to alleviate any miscommunication regarding the encounter in order to increase the chances of a positive experience. A further benefit of selfassessment is clarification of the resident’s goals and of what he or she feels are strengths and areas for improvement so that future activities and encounters can be directed appropriately. Finally, the self-assessment can illuminate discrepancies with the preceptor’s point of view and improve the trainee’s ability to provide an accurate self-evaluation. Feedback tools. Since one of the criteria for effective feedback is that it should be based on observed or firsthand data, it can be useful to include
Clinical pharmacy education
a “360-degree” assessment when considering how to provide feedback.7 This type of assessment is compiled by soliciting information from all types of people who have interacted with the trainee, thus helping to ensure a comprehensive feedback session. Depending on the clinical training setting, the 360-degree approach can be a useful tool for providing feedback from multiple perspectives as well, supporting the identification of areas of positive performance and areas that should be improved from different points of view.7 For example, the preceptor could speak directly with a prescriber, patient, and nurse who has interacted with the resident to ascertain their interpretation of the tenor and content of an interaction. This information can be incorporated into the feedback session to provide alternative perceptions, clear up misconceptions, and strengthen communication strategies and interpersonal relationships. Several other feedback strategies have been described. A common method is the “feedback sandwich,” which begins with comments regarding specific things that went well, proceeds to identification of opportunities for improvement, and then wraps up with a positive vibe for moving forward.8 Relating the feedback to the resident’s goals rather than providing a broad overview, as well as limiting the feedback to a few key points, can enhance the effectiveness of the session. 8 The ARCH feedback method devised by Baker9 recommends the following format: • • • •
Ask the learner to self-assess. Reinforce correct thinking and actions. Correct errors. Help the learner develop an improvement plan.
No matter which format for delivering feedback is chosen, the essential concepts are the same, as described below.
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Striking a balance. The goals of feedback are to reinforce positive performance and to improve future encounters, and it is often necessary to strike a balance between the two. Providing positive feedback builds confidence in a trainee but can also dampen the impetus for change. How much positive feedback is given depends on the trainee and his or her personality and clinical ability. Regardless of how much positive or negative feedback is given, the trainee should feel supported and be urged to remember that the goal is to strengthen clinical skills. Feedback should not be limited to trainees. Those who serve as pharmacists and teachers also have a duty to continue their own clinical development and enhance their teaching skills. One source of useful information in our work toward these goals can be found in our own trainees. Students and residents are the experts when it comes to determining the effectiveness of a preceptor and identifying changes that could improve the learning experience in the future. It is useful to ask a trainee what went well and what could be different to make the experience more effective or more enjoyable. Because many trainees do not feel comfortable making these suggestions face-to-face, providing an anonymous way for them to communicate their feedback might encourage open and honest critiques that will be more useful to the preceptor. Feedback challenges and strategies. Presented below are insights on providing feedback that is effective and well received, generational considerations in providing feedback, and strategies for group feedback sessions and handling strong responses to feedback. Delivering constructive feedback. One of the most difficult aspects of the feedback process is delivering constructive feedback, including feedback in areas where improvement is needed. For example, a 1594
preceptor (or trainee) may be afraid of repercussions after giving negative feedback. Preceptors might worry that a student or resident will shut down and be less engaged in future activities in order to reduce the risk of future criticism. Trainees might not want to critique a preceptor for fear of receiving a low grade, which might set the stage for difficult future encounters, or not earning a positive recommendation. Students and residents might be concerned that documentation of areas of weakness will end up in a permanent record, thereby biasing interactions with future preceptors or limiting job options. However, if opportunities for improvement are not elucidated, no growth can occur. In fact, when no feedback is given, good performance is not reinforced and poor performance remains uncorrected. As a result, trainees assume that all is well, are forced to guess their level of competence, or begin to learn by trial and error at the patient’s expense.1 Providing constructive feedback is a challenge, even for seasoned educators. Therefore, the approach chosen for providing negative feedback is critical. The preceptor should ensure a relaxing atmosphere and compose a script that outlines the important points he or she would like to address. To begin the discussion, the trainee should be given an opportunity to provide the preceptor with a self-evaluation. This gives the trainee a chance to describe how well or poorly he or she completed an assigned task (students and residents are often harder on themselves than their preceptors are); it also provides the preceptor with a better understanding of how the trainee thought through the task. In rare circumstances, it may become apparent that the goals need to be changed altogether based on the trainee’s aptitude. The complexities of human-tohuman interactions in the feedback
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process are often underestimated. It is easy to veer off track, particularly if the recipient of the feedback displays strong emotions or makes excuses. In general, feedback should be limited to one or two issues at a time.1 Concentrate on the most important points, with the intent to highlight others at a later time, after the student or resident has had the chance to refocus. Too much feedback at once, especially if viewed as negative, can be overwhelming. Generational gaps. Each generation brings its own perspectives, beliefs, values, and expectations for learning. A younger generation’s views on authority, structure, and feedback will probably differ from their preceptors’ views. Many students and residency candidates today are part of the millennial generation (also known as Generation Y). Therefore, it is important for preceptors to be familiar with some of the key attributes of this specific group. Millennials, born between 1982 and 2003, expect to be entertained while being educated. This generation is accustomed to receiving high grades (grade inflation was on the rise during their time in school), an expectation that can create challenges when associating a score or ranking with performance in a learning experience. In addition, this generation was raised with constant praise, if for no other reason than for being themselves, making it challenging for them to accept constructive criticism.10 Since members of Generation Y are strongly inclined to incorporate technology into daily life, one might expect them to welcome and be more comfortable with electronic feedback on their performance. However, survey data suggest that this generation of learners prefers face-to-face and handwritten feedback over electronic interactions. Delivering feedback in person gives the learner the opportunity to ask for clarification and encourages his or her active
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engagement in the process. Millenials also have preference for feedback in private and appreciate a personal connection when feedback is provided.11 This generation seeks immediate feedback on performance—what was right and what was incorrect. They might struggle with learning from their errors and are often concerned about what others think of them. It is important to develop specific strategies to help this group improve after making a mistake. Millennials thrive on positive reinforcement, which can create challenges for preceptors who encounter students who need to improve in multiple areas.12 Resistance to feedback. Learners can be resistant (or at least appear to be resistant) to feedback for various reasons. Through verbal or nonverbal communication, a learner might appear agitated or disengaged when feedback is provided. Of particular concern is a student’s failure to incorporate suggestions into his or her practice. Students or residents might argue with or counter constructive criticism. Preceptors must find ways to overcome actual or perceived resistance rather than simply circumvent the process. The preceptor should reflect on how the feedback was provided. Consider if the trainee might have felt embarrassed. Was the feedback presented in front of others? Was the trainee’s intelligence or character questioned inadvertently? The preceptor should determine if any external factors caused the student or resident to ignore or refute the feedback. If the feedback is being given early in the training period, the preceptor should be aware that this might be the first time the learner has received constructive criticism and guidance. To overcome perceived resistance to feedback, the preceptor can employ an alternative strategy the next time. For instance, if the trainee appears to thrive on positive reinforcement or lacks confidence, then a feedback sandwich might work best
for the learner. Starting a feedback session with self-evaluation is also a worthwhile strategy. If the resistance persists, it could be useful to have a discussion with the learner about his or her concerns about the feedback process. The more the trainee is engaged, the higher the likelihood that he or she will be receptive to feedback. A lack of professionalism should be documented if the student or resident continues to be unresponsive or to behave inappropriately when feedback is provided or if the preceptor’s strategies to overcome resistance have been unsuccessful. Options include engaging the residency program director and the school of pharmacy’s experiential learning department. They might be able to provide suggestions for improving the process or to work with the trainee on improving receptiveness to feedback. Emotional reactions. During a formal or informal feedback session, a trainee might become emotional when suggestions for improvement are provided. The preceptor should acknowledge the reaction and give the trainee the opportunity to regain composure, as the failure to address the reaction can lead to further emotional distress and a sense that support is lacking. Educators should attempt to preserve the trainee’s dignity and not punish or scold when an emotional outburst occurs. Instead, they should suggest strategies for controlling emotions in the workplace and explain the importance of doing so. The preceptor should also gauge whether the reaction of the trainee is appropriate given the nature of the feedback. If the preceptor feels comfortable doing so, he or she should ask about the cause of the reaction and give the student or resident the opportunity to voice concerns or problems. The trainee might be experiencing a significant amount of stress because of long work hours,
Clinical pharmacy education
multiple responsibilities, and new challenges associated with the learning experience. External factors might have fed the trainee’s response. The preceptor should be familiar with resources that are available to trainees in these circumstances. If there is cause for concern about the trainee’s safety or well-being, the preceptor should contact the appropriate individual or agency to assist with the situation at hand.13 Providing feedback to multiple trainees. Frequently, preceptors will have more than one trainee on a rotation at a given time. As discussed previously, providing feedback in a group setting can be beneficial at times. Preceptors should take care in comparing the performance of one trainee with another’s. Additionally, each trainee should be provided dedicated time alone with the preceptor throughout the rotation to review individual strengths and areas for improvement. This will allow the preceptor the opportunity to customize the rotation and activities for each trainee and time for each trainee to discuss more specific feedback. When a resident is on rotation with a student, or a PGY2 resident is training with a PGY1 resident, the preceptor may consider highlighting the activities of the higher-level trainee as practices to be modeled; this also allows the senior trainee to provide feedback to the junior trainees in a setting where the preceptor can then provide feedback on how the feedback was delivered. Having multiple learners on rotation allows for an easy strategy to engage the trainees in a peer-to-peer feedback process. For instance, if two students are on rotation together, the preceptor can ask the students to observe each other collecting a medication history and then to provide feedback to each other. This feedback should take place with the preceptor present and will allow another person’s perspective on each student’s performance. Pharmacy residents can
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participate in the same process with each other and can also provide insightful feedback on a student’s performance. This type of process is consistent with the 360-degree process outlined earlier.7 The utility of this type of peer evaluation was assessed among medical interns and senior residents on the same rotation.14 At the end of an inpatient rotation, medical trainees were asked to provide peer evaluations of one another. Elements included on the evaluation included (but were not limited to) medical knowledge, history-taking skills, integrity, and compassion/humanism. Faculty preceptors were also asked to evaluate the trainees using the same criteria. For the majority of domains included on the evaluation, faculty and intern evaluations were well correlated; the largest discrepancy was seen in the evaluations of medical knowledge. At the end of the study period, participants were asked to evaluate the process and the value of feedback from their peers and preceptors. Feedback from peers was highly valued.14
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Conclusion. Feedback is a crucial part of clinical training, but it is often difficult to create and deliver an effective feedback session. By keeping expectations clear, providing timely feedback using specific examples, and avoiding value judgments, clinical educators can improve their skill and confidence in providing feedback. References 1. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ. 2008; 337:a1961. 2. Branch WT, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med. 2002; 77:1185-8. 3. American Society of Health-System Pharmacists. ASHP accreditation standards for residencies in pharmacy practice. www.ashp.org/DocLibrary/Accreditation/ASD-PGY1-Standard.aspx (accessed 2013 Aug 20). 4. Watling CJ, Lingard L. Toward meaningful evaluation of medical trainees: the influence of participants’ perceptions of the process. Adv Health Sci Educ. 2012; 17:183-94. 5. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. www.acpe-accredit. org/pdf/FinalS2007Guidelines2.0.pdf (accessed 2014 Jan 29).
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6. Ende J. Feedback in clinical medical education. JAMA. 1983; 250:777-81. 7. Tumerman M, Hedberg LM, Carlson H. Increasing medical team cohesion and leadership behaviors using a 360-degree evaluation process. Wis Med J. 2012; 111:33-7. 8. Back AL, Arnold RM, Tulsky JA et al. Could I add something? Teaching communication by intervening in real time during a clinical encounter. Acad Med. 2010; 85:1048-51. 9. Baker D. ARCH feedback model for clinical teachers. http://florida.the orangegrove.org/og/items/f08dbd67ca07-5cfe-0a58-8a50784ee6c6/1 (accessed 2013 Oct 24). 10. Effective Teaching and Learning Department, Baker College. Teaching across generations, December 2004. www.mcc. edu/pdf/pdo/teaching_across_gen.pdf (accessed 2013 Oct 24). 11. Budge K. A desire for the personal: student perceptions of electronic feedback. Int J Teach Learn Higher Educ. 2011; 23:342-9. 12. Eckleberry-Hunt J, Tucciarone J. The challenges and opportunities of teaching “Generation Y”. J Grad Med Ed. 2011; 4:458-61. 13. Cannon MD, Witherspoon R. Actionable feedback: unlocking the power of learning and performance improvement. Acad Manage Perspect. 2005; 19(2):120-34. 14. Thomas PA, Bego KA, Hellmann DB. A pilot study of peer review in residency training. J Gen Intern Med. 1999; 14:5514.
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Feedback in clinical pharmacy education Brian Grover, Bryan D. Hayes, and Kristin Watson Am J Health-Syst Pharm. 2014; 71:1592-6
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eedback has been identified as one of the crucial components of clinical training programs.1,2 Specifically within pharmacy education, feedback to improve clinical judgment is noted as one of the main purposes of residency training.3 However, the bulk of feedback literature pertains to other disciplines (e.g., medicine) and, although many of the principles are similar, perspectives on feedback principles as they relate to pharmacy trainees are needed. Even when preceptors feel certain they are providing feedback to trainees, there is some disagreement as to whether that feedback is being received.2,4 Given the importance attributed to feedback for improving clinical competence, the identification of key steps in providing effective feedback seems vital to preceptorship. We have drawn on personal experience and identified several key articles to define effective feedback and present an avenue for providing effective feedback in the clinical pharmacy setting. In addition, we present several pitfalls and challenges that can hinder effective feedback and then offer strategies to overcome them.
What is feedback and why is it necessary? Feedback is the provision of information for the purpose of evaluating or correcting behavior. The Accreditation Council for Pharmacy Education (ACPE) requires a qualityassurance process for all pharmacy practice experiences. This includes a process to provide feedback and to ensure interrater reliability when students’ performances are assessed. Additionally, the ACPE guidelines require that the associated outcomes of the pharmacy practice experiences be documented and assessed and that students have contact with a preceptor to ensure that feedback is received.5 Feedback is also an essential component of residency training and is mandated by several principles in the accreditation standards of the American Society of Health-System Pharmacists (ASHP).3 In fact, for postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) training, the ASHP standards require feedback for both residents and preceptors. Improvement of the feedback process is vital for continued growth of the resident and the training program.3 From a clinical perspective,
Brian Grover, Pharm.D., BCPS, is Clinical Specialist, Internal Medicine and Antithrombosis; and B ryan D. H ayes , P harm .D., DABAT, is Clinical Specialist, Emergency Medicine and Toxicology, University of Maryland Medical Center, Baltimore. Kristin Watson, Pharm.D., BCPS (AQ-Cardiology), is Associate Professor and Residency and Fellowship Program Coordinator, University of Maryland School of Pharmacy, Baltimore.
Address correspondence to Dr. Hayes ([email protected]). The authors have declared no potential conflicts of interest.
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Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/0902-1592. DOI 10.2146/ajhp130701
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feedback has long been noted to play a significant role in the training of clinicians, and the difficulty of providing feedback in an effective manner is well recognized.2,6 Therefore, identifying and disseminating key strategies for ensuring a positive feedback session should improve the overall clinical skills of trainees. The principles described in this article apply to interactions with both pharmacy students and residents. Feedback versus evaluation. The terms feedback and evaluation are often used interchangeably, but actually they are unique entities. The primary difference between feedback and evaluation is the ultimate intent, though from a learner’s perspective they might initially seem the same. The goals of both are (1) to provide information to trainees with the intention of narrowing the gap between actual and desired performance, (2) to encourage learners to think about their performance and how they might improve, and (3) to effect changes in the learner’s thinking, behavior, and performance. 1 Feedback should be used to provide information on actions that were directly observed and the effect of those actions. Evaluation is intended to judge a performance or achievement of a goal, generally at the end of an activity.6 Both feedback and evaluation should enable the trainee to repeat positive behaviors or improve performance when similar situations are encountered in the future. In essence, feedback and evaluation must always be focused on the goal of improvement. This similar purpose might contribute to some of the confusion regarding these terms. A consequence of the ambiguity of these terms is that confusion can lead
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a trainee to misunderstand the intent of feedback or assume that it did not occur. Thus, improving the format and effectiveness of feedback will be useful for everyone involved in training pharmacy students and residents. Setup for success. Guidelines for delivering feedback have been described in the literature for medical education and training in clinical settings.2,6 In general, they discuss appropriate timing and working in concert with the trainee to see that feedback is not a judgment but a tool to help him or her improve. Additionally, feedback should be based on observed findings. It should avoid evaluative statements, be specific, and address decisions or actions rather than intentions or assumptions. The first step toward avoiding confusion about feedback is to set expectations. Without taking the time to describe what goals are to be learned, to express preferences regarding communication style and timing, to delineate requirements for follow-up, and to agree on a format to be followed or specific information to be discussed, the preceptor introduces a setup for potential “failure” in the resident’s mind and possibly for barriers to positive interactions in the future. Once the expectations are explained, it is more likely that feedback will be framed from a place of mutual understanding. To improve dissemination of expectations, one option is to provide the learner with an in-depth description of the rotation. This resource describes, in detail, the goals for the rotation and the activities used throughout the rotation to accomplish them. Each activity might have its own goals, and each activity should contribute to the overall goals of the rotation. Students and residents should also be asked to provide three or four personal goals for the rotation. Setting such goals early on helps create expectations that are clear to both the teacher and
the learner, thereby ensuring that feedback is aligned with a shared understanding of the objectives. Feedback must be provided in the appropriate setting. The idea of feedback is to provide timely commentary on how a particular task or decision was performed; sometimes, it should be provided immediately. Feedback is generally most effective when given soon after a task, particularly if patient care will be affected, but sensitivity to the setting is also necessary. The trainee should be taken aside if the situation poses the potential for embarrassment. Feedback also can be provided in a group setting, particularly when multilevel groups of trainees (e.g., students and residents) are involved, as this approach can facilitate learning and minimize the need to repeat the same concept multiple times. It can be useful to have the trainee formulate a self-assessment before hearing feedback from the preceptor. This process can be initiated by asking the resident to describe how well the activity was performed from his or her perspective, including strengths and areas for improvement. Self-assessment can clarify goals, identify dissonance between expectations, and align the feedback to make certain everyone is “on the same page.” Ultimately, the goal is to alleviate any miscommunication regarding the encounter in order to increase the chances of a positive experience. A further benefit of selfassessment is clarification of the resident’s goals and of what he or she feels are strengths and areas for improvement so that future activities and encounters can be directed appropriately. Finally, the self-assessment can illuminate discrepancies with the preceptor’s point of view and improve the trainee’s ability to provide an accurate self-evaluation. Feedback tools. Since one of the criteria for effective feedback is that it should be based on observed or firsthand data, it can be useful to include
Clinical pharmacy education
a “360-degree” assessment when considering how to provide feedback.7 This type of assessment is compiled by soliciting information from all types of people who have interacted with the trainee, thus helping to ensure a comprehensive feedback session. Depending on the clinical training setting, the 360-degree approach can be a useful tool for providing feedback from multiple perspectives as well, supporting the identification of areas of positive performance and areas that should be improved from different points of view.7 For example, the preceptor could speak directly with a prescriber, patient, and nurse who has interacted with the resident to ascertain their interpretation of the tenor and content of an interaction. This information can be incorporated into the feedback session to provide alternative perceptions, clear up misconceptions, and strengthen communication strategies and interpersonal relationships. Several other feedback strategies have been described. A common method is the “feedback sandwich,” which begins with comments regarding specific things that went well, proceeds to identification of opportunities for improvement, and then wraps up with a positive vibe for moving forward.8 Relating the feedback to the resident’s goals rather than providing a broad overview, as well as limiting the feedback to a few key points, can enhance the effectiveness of the session. 8 The ARCH feedback method devised by Baker9 recommends the following format: • • • •
Ask the learner to self-assess. Reinforce correct thinking and actions. Correct errors. Help the learner develop an improvement plan.
No matter which format for delivering feedback is chosen, the essential concepts are the same, as described below.
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Striking a balance. The goals of feedback are to reinforce positive performance and to improve future encounters, and it is often necessary to strike a balance between the two. Providing positive feedback builds confidence in a trainee but can also dampen the impetus for change. How much positive feedback is given depends on the trainee and his or her personality and clinical ability. Regardless of how much positive or negative feedback is given, the trainee should feel supported and be urged to remember that the goal is to strengthen clinical skills. Feedback should not be limited to trainees. Those who serve as pharmacists and teachers also have a duty to continue their own clinical development and enhance their teaching skills. One source of useful information in our work toward these goals can be found in our own trainees. Students and residents are the experts when it comes to determining the effectiveness of a preceptor and identifying changes that could improve the learning experience in the future. It is useful to ask a trainee what went well and what could be different to make the experience more effective or more enjoyable. Because many trainees do not feel comfortable making these suggestions face-to-face, providing an anonymous way for them to communicate their feedback might encourage open and honest critiques that will be more useful to the preceptor. Feedback challenges and strategies. Presented below are insights on providing feedback that is effective and well received, generational considerations in providing feedback, and strategies for group feedback sessions and handling strong responses to feedback. Delivering constructive feedback. One of the most difficult aspects of the feedback process is delivering constructive feedback, including feedback in areas where improvement is needed. For example, a 1594
preceptor (or trainee) may be afraid of repercussions after giving negative feedback. Preceptors might worry that a student or resident will shut down and be less engaged in future activities in order to reduce the risk of future criticism. Trainees might not want to critique a preceptor for fear of receiving a low grade, which might set the stage for difficult future encounters, or not earning a positive recommendation. Students and residents might be concerned that documentation of areas of weakness will end up in a permanent record, thereby biasing interactions with future preceptors or limiting job options. However, if opportunities for improvement are not elucidated, no growth can occur. In fact, when no feedback is given, good performance is not reinforced and poor performance remains uncorrected. As a result, trainees assume that all is well, are forced to guess their level of competence, or begin to learn by trial and error at the patient’s expense.1 Providing constructive feedback is a challenge, even for seasoned educators. Therefore, the approach chosen for providing negative feedback is critical. The preceptor should ensure a relaxing atmosphere and compose a script that outlines the important points he or she would like to address. To begin the discussion, the trainee should be given an opportunity to provide the preceptor with a self-evaluation. This gives the trainee a chance to describe how well or poorly he or she completed an assigned task (students and residents are often harder on themselves than their preceptors are); it also provides the preceptor with a better understanding of how the trainee thought through the task. In rare circumstances, it may become apparent that the goals need to be changed altogether based on the trainee’s aptitude. The complexities of human-tohuman interactions in the feedback
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process are often underestimated. It is easy to veer off track, particularly if the recipient of the feedback displays strong emotions or makes excuses. In general, feedback should be limited to one or two issues at a time.1 Concentrate on the most important points, with the intent to highlight others at a later time, after the student or resident has had the chance to refocus. Too much feedback at once, especially if viewed as negative, can be overwhelming. Generational gaps. Each generation brings its own perspectives, beliefs, values, and expectations for learning. A younger generation’s views on authority, structure, and feedback will probably differ from their preceptors’ views. Many students and residency candidates today are part of the millennial generation (also known as Generation Y). Therefore, it is important for preceptors to be familiar with some of the key attributes of this specific group. Millennials, born between 1982 and 2003, expect to be entertained while being educated. This generation is accustomed to receiving high grades (grade inflation was on the rise during their time in school), an expectation that can create challenges when associating a score or ranking with performance in a learning experience. In addition, this generation was raised with constant praise, if for no other reason than for being themselves, making it challenging for them to accept constructive criticism.10 Since members of Generation Y are strongly inclined to incorporate technology into daily life, one might expect them to welcome and be more comfortable with electronic feedback on their performance. However, survey data suggest that this generation of learners prefers face-to-face and handwritten feedback over electronic interactions. Delivering feedback in person gives the learner the opportunity to ask for clarification and encourages his or her active
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engagement in the process. Millenials also have preference for feedback in private and appreciate a personal connection when feedback is provided.11 This generation seeks immediate feedback on performance—what was right and what was incorrect. They might struggle with learning from their errors and are often concerned about what others think of them. It is important to develop specific strategies to help this group improve after making a mistake. Millennials thrive on positive reinforcement, which can create challenges for preceptors who encounter students who need to improve in multiple areas.12 Resistance to feedback. Learners can be resistant (or at least appear to be resistant) to feedback for various reasons. Through verbal or nonverbal communication, a learner might appear agitated or disengaged when feedback is provided. Of particular concern is a student’s failure to incorporate suggestions into his or her practice. Students or residents might argue with or counter constructive criticism. Preceptors must find ways to overcome actual or perceived resistance rather than simply circumvent the process. The preceptor should reflect on how the feedback was provided. Consider if the trainee might have felt embarrassed. Was the feedback presented in front of others? Was the trainee’s intelligence or character questioned inadvertently? The preceptor should determine if any external factors caused the student or resident to ignore or refute the feedback. If the feedback is being given early in the training period, the preceptor should be aware that this might be the first time the learner has received constructive criticism and guidance. To overcome perceived resistance to feedback, the preceptor can employ an alternative strategy the next time. For instance, if the trainee appears to thrive on positive reinforcement or lacks confidence, then a feedback sandwich might work best
for the learner. Starting a feedback session with self-evaluation is also a worthwhile strategy. If the resistance persists, it could be useful to have a discussion with the learner about his or her concerns about the feedback process. The more the trainee is engaged, the higher the likelihood that he or she will be receptive to feedback. A lack of professionalism should be documented if the student or resident continues to be unresponsive or to behave inappropriately when feedback is provided or if the preceptor’s strategies to overcome resistance have been unsuccessful. Options include engaging the residency program director and the school of pharmacy’s experiential learning department. They might be able to provide suggestions for improving the process or to work with the trainee on improving receptiveness to feedback. Emotional reactions. During a formal or informal feedback session, a trainee might become emotional when suggestions for improvement are provided. The preceptor should acknowledge the reaction and give the trainee the opportunity to regain composure, as the failure to address the reaction can lead to further emotional distress and a sense that support is lacking. Educators should attempt to preserve the trainee’s dignity and not punish or scold when an emotional outburst occurs. Instead, they should suggest strategies for controlling emotions in the workplace and explain the importance of doing so. The preceptor should also gauge whether the reaction of the trainee is appropriate given the nature of the feedback. If the preceptor feels comfortable doing so, he or she should ask about the cause of the reaction and give the student or resident the opportunity to voice concerns or problems. The trainee might be experiencing a significant amount of stress because of long work hours,
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multiple responsibilities, and new challenges associated with the learning experience. External factors might have fed the trainee’s response. The preceptor should be familiar with resources that are available to trainees in these circumstances. If there is cause for concern about the trainee’s safety or well-being, the preceptor should contact the appropriate individual or agency to assist with the situation at hand.13 Providing feedback to multiple trainees. Frequently, preceptors will have more than one trainee on a rotation at a given time. As discussed previously, providing feedback in a group setting can be beneficial at times. Preceptors should take care in comparing the performance of one trainee with another’s. Additionally, each trainee should be provided dedicated time alone with the preceptor throughout the rotation to review individual strengths and areas for improvement. This will allow the preceptor the opportunity to customize the rotation and activities for each trainee and time for each trainee to discuss more specific feedback. When a resident is on rotation with a student, or a PGY2 resident is training with a PGY1 resident, the preceptor may consider highlighting the activities of the higher-level trainee as practices to be modeled; this also allows the senior trainee to provide feedback to the junior trainees in a setting where the preceptor can then provide feedback on how the feedback was delivered. Having multiple learners on rotation allows for an easy strategy to engage the trainees in a peer-to-peer feedback process. For instance, if two students are on rotation together, the preceptor can ask the students to observe each other collecting a medication history and then to provide feedback to each other. This feedback should take place with the preceptor present and will allow another person’s perspective on each student’s performance. Pharmacy residents can
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participate in the same process with each other and can also provide insightful feedback on a student’s performance. This type of process is consistent with the 360-degree process outlined earlier.7 The utility of this type of peer evaluation was assessed among medical interns and senior residents on the same rotation.14 At the end of an inpatient rotation, medical trainees were asked to provide peer evaluations of one another. Elements included on the evaluation included (but were not limited to) medical knowledge, history-taking skills, integrity, and compassion/humanism. Faculty preceptors were also asked to evaluate the trainees using the same criteria. For the majority of domains included on the evaluation, faculty and intern evaluations were well correlated; the largest discrepancy was seen in the evaluations of medical knowledge. At the end of the study period, participants were asked to evaluate the process and the value of feedback from their peers and preceptors. Feedback from peers was highly valued.14
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Conclusion. Feedback is a crucial part of clinical training, but it is often difficult to create and deliver an effective feedback session. By keeping expectations clear, providing timely feedback using specific examples, and avoiding value judgments, clinical educators can improve their skill and confidence in providing feedback. References 1. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ. 2008; 337:a1961. 2. Branch WT, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med. 2002; 77:1185-8. 3. American Society of Health-System Pharmacists. ASHP accreditation standards for residencies in pharmacy practice. www.ashp.org/DocLibrary/Accreditation/ASD-PGY1-Standard.aspx (accessed 2013 Aug 20). 4. Watling CJ, Lingard L. Toward meaningful evaluation of medical trainees: the influence of participants’ perceptions of the process. Adv Health Sci Educ. 2012; 17:183-94. 5. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. www.acpe-accredit. org/pdf/FinalS2007Guidelines2.0.pdf (accessed 2014 Jan 29).
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6. Ende J. Feedback in clinical medical education. JAMA. 1983; 250:777-81. 7. Tumerman M, Hedberg LM, Carlson H. Increasing medical team cohesion and leadership behaviors using a 360-degree evaluation process. Wis Med J. 2012; 111:33-7. 8. Back AL, Arnold RM, Tulsky JA et al. Could I add something? Teaching communication by intervening in real time during a clinical encounter. Acad Med. 2010; 85:1048-51. 9. Baker D. ARCH feedback model for clinical teachers. http://florida.the orangegrove.org/og/items/f08dbd67ca07-5cfe-0a58-8a50784ee6c6/1 (accessed 2013 Oct 24). 10. Effective Teaching and Learning Department, Baker College. Teaching across generations, December 2004. www.mcc. edu/pdf/pdo/teaching_across_gen.pdf (accessed 2013 Oct 24). 11. Budge K. A desire for the personal: student perceptions of electronic feedback. Int J Teach Learn Higher Educ. 2011; 23:342-9. 12. Eckleberry-Hunt J, Tucciarone J. The challenges and opportunities of teaching “Generation Y”. J Grad Med Ed. 2011; 4:458-61. 13. Cannon MD, Witherspoon R. Actionable feedback: unlocking the power of learning and performance improvement. Acad Manage Perspect. 2005; 19(2):120-34. 14. Thomas PA, Bego KA, Hellmann DB. A pilot study of peer review in residency training. J Gen Intern Med. 1999; 14:5514.
