The role of feedback in workplace-based assessment
The built-in feedback loop is one of the notable advantages of workplace-based assessment over other assessment formats. Workplace-based assessment is based on IMGs seeing real patients, and feedback given enables the setting of action plans for improved performance in the future.
Feedback enables the setting of action plans for improved performance in the future.
A recent survey report of trainees registered in a specialist medical college training program summarised what they considered to be the characteristics of good supervisors:
- Be available to teach
- Be willing to spare time for trainees
- Observe trainees at work
- Give constructive, honest feedback
- Assess regularly and objectively
- Be trained to teach and assess.37
These characteristics also refer to good supervisors of IMGs.
Workplace-based assessment comprises observation (to enable a judgment to be made on performance) and feedback (information that is timely, specific to the IMG’s performance and relevant to effective performance in the workplace).
A study in 1990 by Day et al, citing the low priority traditionally placed on observation, points out that without observation there is no opportunity for the assessment of day-to-day clinical skills or provision of feedback that might lead to improved performance.38 There is a need for observations to be guided by clear and coherent assessment criteria, which can also serve as focal points during feedback discussions with IMGs.
Here are some examples of feedback that are well meaning but unlikely, on their own, to effect change in workplace performance:
- ‘You’re doing fine, really, but you need to improve in some areas.’
- ‘Sometimes you just don’t seem to measure up.’
- ‘They’re saying that you are not a good listener.’
- ‘You need to work on your communication skills.’
- ‘You’re not decisive enough.’
- ‘Where did you learn that?’
- ‘That was a sloppy performance.’
- ‘That was an excellent performance.’
Useful feedback requires time, commitment and precision.
Comments that fail to assist improvement are typically too general, too long after the event, second-hand views, solely negative (negative without including advice for improvement) and/or do not ensure the IMG has understood the advice and knows how to address the problem.
There is no place for personal issues or perceived personality clashes to be raised during feedback on clinical performance. Effective feedback will involve a dialogue between the assessor and the IMG, aiming to identify what was done well and not done well, and helping to develop a plan for improvement. In a feedback session, IMGs should be challenged to address each of these issues, with the assessor doing it for them when they lack the insight to do so on their own. Useful feedback requires time, commitment and precision.
Giving effective feedback
Start with the learner’s agenda when giving feedback. Ask ‘What do you think you did well?’ ‘What do you think needs improvement?’
In giving feedback, some words that describe effective feedback are ‘specific’, ‘immediate’, ‘first-hand’, ‘constructive’, ‘descriptive’, ‘action-affirming’ and ‘adequate’. These descriptors of feedback are outlined as follows:
The feedback is restricted to the task just performed, and does not include comments that refer generally to other events.
The feedback is provided immediately following, or as soon as practicable after, the observed performance.
The feedback describes what has just been observed by the supervisor/assessor, and does not include what others might be saying.
The feedback provides helpful suggestions for improving performance and/or directs the IMG to resources that can assist; it serves to motivate and reinforce desirable behaviour.
The feedback describes what was good about the performance, plus what was missing and what needs to be done to improve; an honest appraisal—which may contain information the IMG would prefer not to hear—is most appropriately delivered through describing what has just been observed and specifying the actions/behaviour that were not satisfactory. Describe behaviours with ‘I’ statements, such as; ‘I observed that…’, ‘This is what I think you did well….’, ‘These are the areas that I saw need improvement’.
The feedback sketches out an action plan—which may be recorded on the spot—to give the IMG a summary of expectations. Encourage self-assessment: ‘How might you try to improve?’ ‘Here are some ways you might like to consider.’ Indicate if there are resources that can support achievement.
The feedback is detailed and clear, and ensures that the IMG has understood the message being given.
Feedback on under-performance
While assessors and candidates would like to see a successful outcome of the assessment process, the reality is that this will not always be the case. Many assessors find giving feedback to candidates difficult where candidates are not proceeding through the assessment process as might reasonably be expected, or have failed their assessment. The most difficult feedback sessions are those with individuals who lack insight and fail to reflect on their actions, or have not been successful in their performance.
It is important that assessors meet their responsibilities in this regard – a poor or failing performance should be recorded as that.
To deal with this situation, assessors will need:
- Training on giving feedback and handling more difficult cases, prior to their appointment as assessors;
- Clear guidelines on the passing standard and calibration;
- The timeline within which assessment must be completed;
- Information on opportunities for remediation;
- Information on the processes for:
- the re-assessment of candidates;
- reporting to appropriate authorities any serious negative outcomes from the assessment process;
- handling reviews and appeals, with formal processes to handle appeals in a manner that adheres to the principles of procedural fairness.
It will assist candidates in this situation to:
- Receive clear, timely and ongoing feedback so that they have had advance warning of their performance issues;
- Have clear information about the assessment processes and processes for appeals.
For the assessment system to be robust and defensible it is important that:
- There are fair and transparent processes;
- Valid and reliable methods are used, data are appropriately collated, standards are set, results are defensible and methods are accurate;
- Processes are followed for all candidates, without exception;
- Well documented and public processes are in place to handle complaints/appeals.
For more information on feedback to candidates, visit the Giving Effective Feedback resource of this website.
37 Long EM. Report of a survey of the ACD in-training assessment system. The Australasian College of Dermatologists 2007.
38 Day SC, Grosso LG, Norcini JJ, Blank LL, Swanson DB, Horne MH. Residents’ perceptions of evaluation procedures used by their training program. J Gen Inter Med 1990;5;421-426