If you subscribe to the KeyLIME Podcast, you have likely heard Linda, Jason, and Jon debate whether medical education researchers have exhausted the study of feedback. There have been many published studies concerning feedback in the health professions since the term was first popularized in medicine in 1983 — and perhaps we clinician educators should draw our conclusions, pack up our toys, and move on to research other topics?
To spare you a tedious review of the feedback literature, allow me to summarize the major research findings over the last 35 years: (1) feedback is important, and (2) the quality of feedback varies widely. Research studies generally focus on ways to improve feedback quality and delivery, while taking for granted the basic assumption that feedback is important.
But why is feedback important?
Take a brief pause in your reading of this blog post and answer that simple question, “Why is feedback important?”
Seriously, stop reading and reflect for a moment. Move on when you have your answer.
“Feedback is about relationship building, not simply about performance improvement,” said Lisa Stefanac of KSE Leadership, as she began her half-day workshop at a recent residency program retreat for the Stanford/Kaiser Emergency Medicine program. The retreat was designed to provide our residents and faculty members with key skills to strengthen their personal resiliency, reduce burnout, promote physician wellness, and nurture our professional relationships. So why did we include a workshop on feedback at a wellness retreat?
Feedback is a critical interpersonal communications skill that greatly impacts team dynamics, and thereby, the health of our clinical learning environment. A safe and healthy learning climate is a key driver of trainee wellness. Psychological safety in the workplace is dependent upon positive working relationships with one another.
Reconsider the importance of your professional relationships with your learners or peer colleagues the next time you give them feedback. Are you communicating at your best? Are you providing feedback that will strengthen your relationships with your trainees?
The Feedback Formula is a 6-step method to help you navigate a feedback discussion through the lens of relationship building and behavior change. The 6 steps:
- Ask permission
- State your intention
- Name the behavior
- Describe the impact
- Inquire about the learner experience
- Identify the desired change
- Ask permission: “May I give you feedback?”
There are two types of people. Some of us want real-time feedback — timely feedback is more concrete for certain learners, allowing for immediate and actionable change. However, other individuals have a difficult time receiving feedback in the clinical unit and then task-switching back to patient care. Asking permission before giving feedback removes this burden for trainees and allows them some control in the relationship. The learner may not have control over what feedback will be given, but they still maintain control over the timing. If the learner prefers to delay the feedback conversation, schedule a meeting in the next 1-2 weeks to provide the feedback in a different environment. Don’t wait more than 2 weeks though! Timely feedback ensures a shared memory about the experience, which is a critical element of high-quality feedback.
- State your intention: “I want you to succeed in your new role as the Code Team Captain and I have some suggestions for how you can do even better than you did today.”
Set the tone for the feedback discussion in a positive manner by communicating your intentions for giving feedback. You want your trainees and colleagues to do their best, to achieve their goals, and to provide exceptional patient care. Your professional relationships are strengthened when these are your stated intentions. “I want you to be great and something is getting in the way. If you just do this one thing differently, I’m confident you will experience an improvement in your performance.”
Remember to ‘feed-forward’ with positive appreciation, as opposed to only constructive ‘feed-back’. Regularly describe your observations of what works well, so trainees have a clear understanding of how to continue performing in an excellent manner. Separate ‘feed-forward’ from ‘feed-back’ discussions, to emphasize the importance of the positive behaviors. In other words, separate the ‘bun from the meat’ to do away with traditional feedback sandwiches, an outdated formula no longer considered effective for providing feedback.
- Name the behavior: “During that resuscitation, I observed that you did not assign roles for your team members and did not use closed-loop communication. These techniques are important if you want to succeed as the code team captain.”
Behavior-based feedback is the only feedback that can be observed. It represents a blind spot for the learner – and you are acting as the mirror. Focus your feedback on behaviors, not the individual as a person. Ensure that you maintain your positive professional relationship by valuing the individual, while requesting a behavior change that directly relates to the intent that you stated.
- Describe the impact: “Several times during the code you requested that a task be completed, but you didn’t assign anyone to complete the task. It resulted in delays in medication administration and a delay in central venous access.”
People will only change their behavior when it is in their best interest. Identify what matters most to a learner and speak in that currency. Challenge the learner about their behavior: is it helping them meet their goals, or is the behavior costly to their success?
- Inquire about the learner experience: “I’m curious what you observed or experienced as the team captain. What do you think went well? What improvements could be made next time?”
Recognize that you observed a behavior and drew conclusions based on your observation. These conclusions, a narrative that you create for yourself, may be inaccurate. Therefore, you must inquire about the experience of the trainee in the same situation. Perhaps the trainee asked for a medication during the code and made eye contact with a nurse whose named she did not know? Maybe the delay in administration was for another reason? Only feedback that reflects the shared experience of an observable action will lead to behavior change.
- Identify the desired change: “I want you to use closed-loop communication during resuscitations. Ask each of the nurses’ names when you are the team captain. Request a task of a specific nurse by name, so that he is assigned primary responsibility for completing the task in a timely manner. Closed loop communication will result in a more efficient resuscitation. What other suggestions do you have for improving efficiency during codes?”
State the desired change in behavior and offer a picture of a desired future. Allow the feedback conversation to evolve into joint problem-solving that strengthens your professional relationship. You and your trainee share the responsibility for changing behavior and realizing the desired future.
The Feedback Formula can be used in both oral and written communication. Focus on steps 3, 4, and 6 when completing a written evaluation or feedback tool. Example:
“Areas for Improvement
Behavior: I noticed that you did not use the nurses’ names during the resuscitation.
Impact: The code was inefficient because tasks were not assigned properly.
Desired Change: Use closed-loop communication when you are the code team captain.”
Lastly, all parties who engage in feedback discussions should be trained to give – and receive – feedback using The Feedback Formula. We included this training workshop in our resident retreat so that everyone would speak in a common language. But what happens when a resident expects to receive feedback using the Formula, but an instructor delivers the feedback in a much more negative manner? How can the trainee pivot the feedback conversation in order to understand the desired behavior change and preserve their relationship with their professor?
We will address this dilemma in the next post, THE FEEDBACK FORMULA: Part 2, Receiving Feedback.
Lisa Stefanac, MBA is Co-Founder and Partner of KSE Leadership LLC in San Francisco, CA. She focuses on leadership development, team effectiveness, and talent management for small and large companies, and across industries. Lisa is on staff at Stanford Graduate School of Business, where she facilitates interpersonal dynamics, coaching, and mentoring courses for the MBA program.