CHAPTER 5: DISCUSSION, CONCLUSION AND RECOMMENDATIONS
5.2 Main findings and Conclusion
5.2.3 Question 3: How does the addition of a feed-forward strategy to the clinical skills logbook
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established. Clinical teachers, therefore, played an important role in facilitating students’ feedback literacy through creating suitable environments by providing students with opportunities to use feedback within the curriculum. Through these learning experiences, teachers have played an important role in students understanding of what feedback is, and how effectively it can be managed.
They developed the capacity of the student to judge their work and helped to make sense of the feedback information that ultimately encouraged feedback use to inform future work, thus closing the feedback loop.
5.2.3 Question 3: How does the addition of a feed-forward strategy to the clinical skills
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practice component scores of the written feedback comments (Abraham & Singaram, 2019). The study indicated that although the written feedback comments contained all three deliberate practice components, both the tutor and peer feedback comments were of moderate quality. The performance gap was described specifically, while the task and action components generally described in terms of their individual descriptions to help learners clarify things they might not have understood, and the feedback may not always be effective. Giving specific feedback targeting the task level based on the task performance, defining specific learning goals that need enhancement and explaining how the task could be completed in the future, is considered to be most successful (Kluger & DeNisi, 1996).
Poorly informed feedback is known to reduce the value of feedback for learners (Lefroy et al., 2015;
Robinson et al., 2013; Weaver, 2006). While high-quality feedback should be accurate, relevant to the learning background, timely, balanced, constructive, and include an improvement plan, it is also critical for educators to remember that the recipient should be responsible for developing a learning and action plan with goals to enhance the student agency. As too much feedback will hinder self- regulated learning, the feedback provider, should only facilitate these processes. In this study, with tutors as well as peers specifically identifying the performance gap in the written feedback, there is evidence that the feedback improvement strategy as a feed-forward intervention had a positive impact on the feedback provision. Constructive feedback that identifies deficiencies in performance can promote self-regulation by stimulating self-awareness and self-directed monitoring by reflecting in action (Lefroy et al., 2015). It thus assists learners in “deep processing and mastery of tasks” (Archer, 2010, p.103) in order to resolve the difference between their actual performance and their desired performance. This actionable feedback can help students create growth strategies by building on their strengths and overcoming performance deficiencies to move beyond their current performance (Sadler, 2010; Watling et al., 2014).
The quality of feedback given to students in the third year was found to be higher than that given to students in the second year. There is a possibility that the longitudinal teacher-learner relationships that had developed over the year, as perceived in our first study, contributed positively to the delivery of feedback. Bok et al. (2013) stated that as medical learners build relationships with teachers’ over time, the goals of the teachers and learners’ converge, and the learners tend to trust the validity of their feedback. Previous studies have frequently reported feedback not distinguishing the level of learners’ competence (Hawkins et al., 1999). Our study findings reported a correlation between the global feedback rating and feedback quality. This explains the fact that tutors and peers spending time and thought on making reasonable observations are evaluating the level of performance of the learner correctly.
This study also found that as students’ level of academic performance increased, the performance gap and action feedback scores decreased. This indicates that educators find it difficult to locate a flaw in
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the higher achieving students’ performance, and instead of concentrating on the academic appraisal of a single skill (Gauthier et al., 2016), they would prefer to test higher-order integrated learning activities that involve application of clinical knowledge such as problem-solving and clinical reasoning (Griffith et al., 2016). This supports the study participants’ request in the first study on the need for developing integrated skills assessments using clinical case scenarios, with feedback that was perceived to enable their reflection and self-regulatory learning skills towards promoting clinical competence. Interestingly, no significant difference was found in our study between the quality of the tutor and peer feedback (Abraham & Singaram, 2019). Hence investing in the development of students as peer assessors is a valuable resource, particularly in a resource-constrained educational setting with large groups of students and limited clinical teachers. Training students as peer assessors can also promote learner interaction through feedback, self-reflection, evaluative judgment, clinical skills training and self-regulatory learning skills needed for lifelong learning (Mann et al., 2009).
Feedback works better if the feedback culture in the educational environment systematically integrates feedback into the learning process. This enables teachers and peers to provide directly observed verbal and written feedback through several formative assessment sessions. The clinical skills logbook feedback aided medical students’ reflection to track their learning purposes and served as a feedback tool to facilitate self-assessment, peer assessment and discussions with tutors and peers.
This nurtures an environment that enables performance by providing and seeking feedback.
The study recommends the need to put in more effort into improving the way feedback comments are formulated by providing the feedback provider with the feedback-scoring tool to review and score their own feedback for the presence of features of high-quality feedback. This would guide teachers and peers to give good quality feedback thereby enhancing their feedback skills. As reflection is (always) tied in with feedback, and perhaps faculty also require some training in practising this. After all, if we expect our students to reflect on what they do, faculty should also be able to do the same (“Walk the talk”). The Clinical skills tutors will therefore also require training in the use of the feedback tool that has been developed.
It is however necessary but not sufficient to only build in faculty development programmes to enhance the delivery of performance feedback. Feedback between the teacher and student needs to take into account what the teacher delivers as well as how the student engages and responds to it.
Throughout medical education, the emphasis is increasingly on how clinical educators create and provide feedback instead of evaluating how students receive, react and use feedback. This can explain why feedback quality remains a challenge. Based on the findings from the three studies in this research it is therefore vital that assessing quality feedback should examine the whole feedback process instead of any single-stage such as lecturer output to determine the impact feedback has on learners’ professional growth (Nicol, 2010; Wiliam, 2011).
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In summary, this research study confirms that designing participatory feedback initiatives within the clinical skills setting, such as interventions to improve tutor and peer feedback content delivery through the clinical skills formative logbook peer and teacher assessment that included multiple tasks, nurture learners’ active feedback utilization. It shapes learners’ behaviour by targeting higher-order skills to develop their feedback literacy skills. The study unfolds the academic journey towards the development of learner feedback literacy. This suggests that the relationship between feedback efficiency and eventual learner achievement depends on the feedback quality received from the feedback providers and the reliability of the self-directed feedback interaction of the learner. These ultimately lead to learner development of reflective and self-evaluative skills, proactive feedback use to feed-forward to future performance, as well as improved quality of the feedback dialogue between the feedback receiver and sender.