CHAPTER 5: DISCUSSION, CONCLUSION AND RECOMMENDATIONS
5.4 Balancing responsibility sharing to remove barriers to feedback engagement: A new concept to
Based on our research findings, we conclude that the impact of the feedback process lies in the balance of responsibility between the teacher and learner. Some obstacles hinder a significant
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participation of medical students in the clinical learning environment with feedback. Promoting the learning of students’ is often portrayed as lying primarily with their clinical teachers. Competency- based medical education argues that, with a step toward constructivism, successful learning requires students to support and share responsibilities for their educational growth with their teacher.
Developing a philosophy of mutual responsibility for feedback is important, as it guarantees that both students benefit entirely from the feedback they receive through their constructive participation, and ensures the continuity of the positive feedback practices of the teacher (Nash & Winstone, 2017).
Our study shows that the responses of students’ focused mainly on issues that their teachers could do to facilitate their best use of feedback, such as ‘suggestions should be more precise, positive and thorough’ in order to know what to do for their future performance evaluation. They seldom mentioned what they could do and stated vague comments such, as ‘they would work hard close to the exams’. Perceptions of factors preventing students from using feedback as criticized by many educators were students’ weak motivation to deal with feedback provided (Housell et al., 2005). The various barriers mentioned in our study frequently come in the way of learners, preventing them from proactively engaging with feedback and thus stopping their development of skills. The blame-game between students and educators for the failings of feedback further prevents breaking down these barriers to make a difference.
Applying the concept of a psychological framework from Winstone et al. (2017) to our clinical skills medical education settings is critical in addressing facilitators and barriers to feedback receptivity. In order to resolve problems, we need to think more specifically about the sharing of responsibilities and the different responsibilities based on this framework.
This sharing of responsibility between educators and students requires that students and teachers understand the different ways in which they can work together to eliminate barriers to evaluation feedback. Nash & Winstone (2017) have argued that educators have the greatest power to bring forward proactive changes to their students, despite the overall focus of responsibility between students and educators. They indicated that increasing students’ motivation to engage with feedback would initiate a virtuous cycle that will in turn make it easier for both educators and students to further sort out the barriers. For example, increased motivation might steer students to devote more of their time in analysing the feedback they receive, as well as show more interest in seeking feedback and taking up offers for further dialogue around feedback. Increasing students’ willingness to benefit from opportunities of discussions around feedback should in turn, provide educators with better chances of fulfilling their own responsibilities (Nash & Winstone, 2017).
As an example of responsibility-sharing that could improve the validity and acceptance of feedback information, I would like to consider a common situation in our clinical skills laboratory when a student receives directly observed verbal and written feedback after performing an examination skill
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during the formative clinical skills logbook assessment. The responsibility of the educator should be to ensure feedback provided on the directly observed skill is clear, balanced and specific. The feedback should be related to the examination skill’s learning and assessment objectives to address the challenge of lack of ‘awareness’ of what feedback means to the student. The student’s responsibility, on the other hand, is that they should seek clarification on the importance or the meaning of their feedback.
To address the barrier of ‘cognizance’ and techniques that students might use to implement feedback, educators must integrate into the curriculum exercises to train students in implementing feedback skills, while avoiding hypothesizing students’ knowledge of feedback strategies. This would require developing students’ assessment and feedback literacy through initiating their reflection, self- assessment, and peer-assessment as part of the feedback process, which ultimately enhances their self- regulation in learning, and incorporation of feedback. On the other hand, students should be responsible for deciding which approaches they can use to incorporate suggestions, testing new approaches, and deciding where to seek assistance.
In this context, educators could ensure that they develop innovative integrated approaches to make sure that the feedback is relevant to the future practice of the medical student as a doctor in order to overcome ‘agency’ issues. This requires provision of realistic feedback on integrated clinical skills using an integrated case scenario that involves multiple skills to facilitate learning through clinical reasoning and problem solving. This enhances learners’ critical thinking and self-regulated learning.
Educators should also avoid too specific feedback to an exam skill, as their transfer can be restricted.
Therefore, the feedback statements should be linked to the level of the curriculum rather than to the learning outcomes of the module level. Students, on the other hand, must recognise their responsibility to put in the hard work to develop self-generated action plan goals and draw out common themes across assessments to facilitate feedback transfer from one context to another (Carless, 2015).
In order, to eventually, overcome ‘volition’ problems, opportunities for frequent dialogue should be implemented through constructive feedback activities organised in a motivational way, such that the learners feel improvement is possible. On the other hand, students need to be open to improving their responses and be able to deal with the feelings resulting from feedback advice (Bing-You et al., 1997). Furnishing learners with feedback recipience skills such as assessment literacy, self- assessment, motivation, goal defining and self-regulated learning (Winstone et al., 2017) along with promoting shared responsibility between clinical educators and learners’, enables development of self-directed learners with learners’ greater control over assessment and feedback process.
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Implementing responsibility sharing in practice will depend on the various disciplines and will vary across different levels of education. In summary, facilitating students’ engagement with feedback in the undergraduate pre-clinical medical curriculum will require a variety of interventions:
1. Establishing a positive learning environment through multiple opportunities of directly observed on-going formative assessment feedback that normalises the provision of feedback on strengths, as well as areas for improvement. This is essential if the focus is on promoting continuing performance improvement and professional growth. It requires developing clinical skills protocols with learning and assessment outcomes and using self- and peer-assessment exercises. These interventions facilitate reflection, informed self-assessment and co-regulated learning (Rich, 2017) as a means to create opportunities for learners to incorporate feedback and improve their academic and feedback literacy.
2. Designing feedback interventions based on multiple integrated skills that facilitate self- regulated learning and are relevant to the competencies of becoming a medical doctor.
3. Training medical students to be feedback literate through the use of post-evaluation performance and feedback reflection forms, to coach them on how to analyse and implement feedback by setting self-generated action points that can be used for future performance assessment.
All these different interventions have their strengths and limitations. Nevertheless, the focus of the choice and development of each intervention should be on what feedback receiving mechanisms or skills requires addressing, such as encouraging reflection in practice, self-evaluation, appraisal awareness, and drive for engagement, setting goals and self-regulation (Winstone et al., 2017). The shift in behaviour is likely, if students formulate and calibrate their own goals, and discuss the steps, taken to achieve these objectives. As medical students aim to become future reflective practitioners, for future improvement they should initiate action plans. Autonomy is a phenomenon of growth, so clinical teachers will have to balance supervision with autonomy through a continuum of external guidance, gradually leading through to shared guidance and shared responsibility between teachers and learners and, finally, to internal support, where students are competent to practise independently (Ten Cate et al., 2004). It is equally important to have on-going dialogue with students in order to supply feedback to the faculty about the feedback process and their feedback psychological experiences.
Weaver (2006) and Burke (2009), however, mentioned that higher education students have never received systematic guidelines on how to effectively receive and act on feedback. With the increasing diversity and multi-cultural student body in higher education, these discussions need to be initiated with students about why interacting with feedback is relevant, what the obstacles are to engaging with
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feedback, and what kinds of emotional responses can be associated with receiving negative feedback (Nash & Winstone, 2017).
An earlier study showed that although linguistic and cultural differences do not appear to affect the feedback process, the clinical instructor was concerned about stereotypes that could be attributed to giving feedback in a multicultural divide that included different cultural and linguistic backgrounds in our simulated clinical setting (Abraham & Singaram, 2016). A teacher stated, ‘For second-language students the delivery of feedback is important. Also, from a cultural perspective, students may see me as a figure of authority and misconstrue my feedback as “scolding”’ (Abraham & Singaram, 2016, p.124). The feedback may not, be interpreted as a way of encouraging future development but as a sign of failure. Such sensitive feedback can limit the students’ participation in the feedback process.
Therefore, these discussions on feedback barriers confirm that student demographics and cultural background can potentially influence their feedback-receiving experiences. Hence, training students to handle feedback in terms of anticipating feedback and resisting defensive feedback would be beneficial. In light of the increasing diversity in medical education settings, the influence of cultural backgrounds could be explored further, although these influences did not emerge in this study.
Finally, achieving a culture of responsibility sharing would require co-operation from both the students and clinical teachers about this approach. We will have to promote the awareness of medical students that constructive interaction with feedback does more than interpret their skills, but has long- term goals as a sustainable and transferable lifelong ability, which will eventually support them in their career and job prospects. According to McGrath et al. (2015), long-term learning benefits perceived as distal targets as a measure of graduate jobs, go beyond the immediate satisfaction of the student with sharing responsibility. Nevertheless, Nicol (2010) noted that the workload of the teacher is a major factor in her feedback practice and it is labour-intensive to create a culture of responsibility sharing, requiring her to invest more time. There is therefore the need to get clinical educators to recognize that they can maintain their feedback-related workload in the long term by investing time in these efforts to address student feedback barriers. It has the greatest potential to reduce the immense burden of providing more and more feedback by inspiring learners to be involved in recognizing and using feedback, as well as producing and seeking feedback. Achieving these distal goals of proactive engagement is reasonable to imagine, as this is consistent with the institutional goals of promoting supportive shift towards responsibility sharing.
Our study highlights the numerous facilitators and barriers that prevent students from proactively engaging in feedback. The culture of sharing responsibility which we discussed is based on the assumption that both educators and students have similar and distinctive roles in overcoming these barriers with an intrinsic degree of mutual cooperation, and that these barriers cannot be met in isolation by either educators or students. Educators delivering high-quality feedback can never be
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successful and impactful unless students are willing to receive and use it, and a cultural shift towards sharing in their responsibilities to the feedback process is therefore necessary.