Variables that affect the process and outcome of feedback, relevant for medical training: a meta-review.

CONTEXT: Feedback is considered important in medical education. The literature is not clear about the mechanisms that contribute to its effects, which are often small to moderate and at times contradictory. A variety of variables seem to influence the impact of feedback on learning. The aim of this study was to determine which variables influence the process and outcomes of feedback in settings relevant to medical education. METHODS: A myriad of studies on feedback have been conducted. To determine the most researched variables, we limited our review to meta-analyses and literature reviews published in the period from January 1986 to February 2012. According to our protocol, we first identified features of the feedback process that influence its effects and subsequently variables that influence these features. We used a chronological model of the feedback process to categorise all variables found. RESULTS: A systematic search of ERIC, PsycINFO and MEDLINE yielded 1101 publications, which we reduced to 203, rejecting papers on six exclusion criteria. Of these, 46 met the inclusion criteria. In our four-phase model, we identified 33 variables linked to task performance (e.g. task complexity, task nature) and feedback reception (e.g. self-esteem, goal-setting behaviour) by trainees, and to observation (e.g. focus, intensity) and feedback provision (e.g. form, content) by supervisors that influence the subsequent effects of the feedback process. Variables from all phases influence the feedback process and effects, but variables that influence the quality of the observation and rating of the performance dominate the literature. There is a paucity of studies addressing other, seemingly relevant variables. CONCLUSIONS: The larger picture of variables that influence the process and outcome of feedback, relevant for medical education, shows many open spaces. We suggest that targeted studies be carried out to expand our knowledge of these important aspects of feedback in medical education.

Feedback providers' credibility impacts students' satisfaction with feedback and delayed performance.

PURPOSE: Medical students receive feedback during clerkships from many different sources: attendings, residents, paramedics, other clerks and even patients. Not all feedback providers have similar impact on learning. One characteristic that is believed to have impact is their credibility to the recipient. This study investigates the effects of feedback provider credibility on medical student satisfaction, self-efficacy and performance with a trained skill. METHODS: A single-blind randomized controlled between-subjects design was used, with feedback provider credibility (high-low) as independent variable and examination of hearing abilities as the task. First year medical students' (n = 68) satisfaction, self-efficacy and performance were the dependent variables and were measured both directly after the intervention and after a three-week delay. RESULTS: Credibility did not significantly affect immediate or delayed self-efficacy. Students receiving feedback from a high-credibility source were more satisfied with the feedback. They did not perform significantly better immediately after the feedback intervention, but did so three weeks after the intervention. High credibility was associated with a perception of a negative feedback message and an unsocial feedback provider. CONCLUSIONS: Feedback provider credibility impacts satisfaction with feedback and delayed performance. If feedback is not effective in clinical settings, feedback providers may reconsider their credibility.

Framing of feedback impacts student's satisfaction, self-efficacy and performance.

Feedback is considered important to acquire clinical skills. Research evidence shows that feedback does not always improve learning and its effects may be small. In many studies, a variety of variables involved in feedback provision may mask either one of their effects. E.g., there is reason to believe that the way oral feedback is framed may affect its effect if other variables are held constant. In a randomised controlled trial we investigated the effect of positively and negatively framed feedback messages on satisfaction, self-efficacy, and performance. A single blind randomised controlled between-subject design was used, with framing of the feedback message (positively-negatively) as independent variable and examination of hearing abilities as the task. First year medical students' (n = 59) satisfaction, self-efficacy, and performance were the dependent variables and were measured both directly after the intervention and after a 2 weeks delay. Students in the positively framed feedback condition were significantly more satisfied and showed significantly higher self-efficacy measured directly after the performance. Effect sizes found were large, i.e., partial η (2) = 0.43 and η (2) = 0.32 respectively. They showed a better performance throughout the whole study. Significant performance differences were found both at the initial performance and when measured 2 weeks after the intervention: effects were of medium size, respectively r = -.31 and r = -.32. Over time in both conditions performance and self-efficacy decreased. Framing the feedback message in either a positive or negative manner affects students' satisfaction and self-efficacy directly after the intervention be it that these effects seem to fade out over time. Performance may be enhanced by positive framing, but additional studies need to confirm this. We recommend using a positive frame when giving feedback on clinical skills.

Teacher competences required for developing reflection skills of nursing students.

AIM: This paper is a report of a study in senior secondary vocational education designed to develop a framework for teacher competences to support nursing students in developing their reflection skills. BACKGROUND: For healthcare-related professions such as nursing, there is a growing attention for developing reflection skills. Little is known about teacher competences required to support the development of reflection skills in nursing students. Developing a framework of teacher competences can contribute to filling up this gap. These competences are described in 91 indicators distributed over six task domains. METHODS: A Delphi study was conducted in the first half year of 2008 to get consensus on a framework of teacher competences required for creating the learning environment needed for developing reflection skills in nursing students. Experts judged teacher competences on a seven-point Likert-type scale. FINDINGS: In the first round, mean scores on the teacher competences were already high. Minor revisions were needed. In the second round, mean scores increased, whereas standard deviations decreased in round 2 compared with round 1. These changes were statistically significant. Coaching was seen as most important task domain. CONCLUSION: Consensus has been reached on teacher competences to be used in nursing education to develop students' reflection skills. The framework of competences may be a source for curriculum development concerning reflection skills and for teacher training programmes to coach nursing students' reflections.

What is feedback in clinical education?

OBJECTIVE: Feedback is important in clinical education. However, the medical education literature provides no consensual definition of feedback. The aim of this study is to propose a consensual, research-based, operational definition of feedback in clinical education. An operational definition is needed for educational practice and teacher training, and for research into the effectiveness of different types of feedback. METHODS: A literature search about definitions of feedback was performed in general sources, meta-analyses and literature reviews in the social sciences and other fields. Feedback definitions given from 1995 to 2006 in the medical education literature are also reviewed. RESULTS: Three underlying concepts were found, defining feedback as 'information'; as 'reaction', including information, and as a 'cycle', including both information and reaction. In most medical education and social science literature, feedback is usually conceptualised as information only. Comparison of feedback definitions in medical education reveals at least 9 different features. The following operational definition is proposed. Feedback is: 'Specific information about the comparison between a trainee's observed performance and a standard, given with the intent to improve the trainee's performance.' CONCLUSIONS: Different conceptual representations and the use of different key features might be a cause for inconsistent definitions of feedback. The characteristics, strengths and weaknesses of this research-based operational definition are discussed.