CHAPTER 5: DISCUSSION, CONCLUSION AND RECOMMENDATIONS
5.2 Main findings and Conclusion
5.2.2 Question 2: How do medical students’ of different academic levels perceive self and peer-to-
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external and internal. Some of the external factors included language as a barrier in the multicultural and diverse student population, and learners’ perceptions of the feedback process as being timely, relevant, credible, personalized, and constructive. The internal factors were learners’ receptivity to constructive feedback, the extent to which tutors’ expectations differed from their perceived self- assessment, learned helplessness, lack of self-confidence to demonstrate a skill, overwhelming workload and sometimes, a lack of effective strategies to implement feedback. Engagement with feedback was perceived by our study participants as encompassing a trustful relationship with commitment of both the receiver and sender to the feedback process. To promote motivation and self- regulation, educators will need to develop practices that prevent students’ dependence only on how feedback instructions are delivered but also focus on developing their self-reflection and self- assessment through involvement in the feedback process (Lefroy et al., 2015). This study suggests the need for shared responsibility for both the teacher and the learner to identify and overcome the barriers and foster feedback receptivity enablers. The aim is to promote learners’ active participation in the feedback process with feedback considered important to encourage behavioural change.
5.2.2 Question 2: How do medical students’ of different academic levels perceive self
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feedback to performance criteria, without relying exclusively on teachers for their authoritative opinion (Quinton & Smallbone, 2010). Higher achieving participants in our study, similar to findings from Srinivasan et al. (2007), valued educators’ need to prompt self-assessment as it improved their self-assessment skills. Self-assessment was viewed as encouraging their feedback reflection to establish learning objectives (Bounds et al., 2013), as a way of working to self-regulate their learning and narrow their performance gaps by changing behaviour and improving performance. Self- assessment as internal feedback prompted the learners to question their approaches to learning (Moon, 2002), hence making them assessment literate which supports their transference of learning (Quinton
& Smallbone, 2010). The lower performing students, however, saw the limited literacy of the evaluation that they and their peers had as a challenge to engage with these interventions effectively.
Similar to other studies (Boud et al., 2013; 2015), multiple self-assessment opportunities through tutor and peer evaluation and feedback processes were perceived to stimulate confidence in the students judging their performance standards over time.
Faculty orienting learners to the learning task was built into the clinical skills environment to develop learner feedback and assessment literacy, by emphasizing essential characteristics of the task through the clinical skills protocol that included performance standards and evaluation criteria. All participants confirmed that this intervention enabled them to develop relevant knowledge, skills and competencies to understand and apply task-based learning goals and make judgments about their own performance and the performance of others. Similar to the findings of Price et al. (2012), knowing the expected performance goals helped learners understand the terminology, concepts and techniques used during peer evaluation and feedback process. Through integrating peer evaluation requiring peers to provide actionable feedback in the contexts of clinical skills, medical educators have used this as a forum to promote continued learner self-assessment, assessment literacy and goal-setting. These are a means to fostering the development of action plans. Winstone et al. (2017) pointed out that the setting of goals involves demonstrating evidence of critical thinking in order to adopt behaviours aimed at achieving the desired results. The study confirms that the culture of clinical skills logbook feedback contributed to the goal setting and enhancement of self-regulation skills by the learners, which is an evolving development of evaluating and monitoring their own progress and learning strategies. It is therefore fair to recognize that goal-setting encouraged students’ active engagement with feedback, encouraging them to read and understand feedback, recognizing areas for growth, establishing academic objectives and then translating these goals into practice through behavioural adjustment (Winstone et al., 2017). These interventions encouraged the students’ open-ness to receive feedback from the willingness to start engaging with their performance (Handley et al., 2011), by considering feedback, including it, and relating it to their learning process (Price et al., 2011).
This study further highlights the value of peer-peer interactions as a social element of learning to implement feedback to feed-forward, by developing learning evaluation opportunities and behaviour
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changes when done genuinely. Student behaviour perceived from this study as improved feedback interactions during the peer assessment and feedback sessions, included activities such as students picking up a time to meet with their peers, meeting individually in a quiet place without interruptions in the skills laboratory and scheduling a time for the next peer feedback session before concluding a meeting. Peer feedback as a dialogue helped learners to understand concepts and apply their understanding of these concepts in learning tasks. The higher achieving students reported the benefits of the peer assessment opportunity as not just giving feedback, but also, the need to challenge their own work in the process of developing feedback. This makes them critical reflective observers of their own learning, which is a step towards becoming a self-regulated learner. This study, however, revealed varied responses to the benefits of giving peer feedback, as learners queried the credibility of the peer feedback such as peers may lack a clear understanding of how to give feedback. They dismissed feedback they perceived as lacking credibility, which was often influenced by the depth of peers’ medical knowledge and friendship bias. Following qualitative studies, Bing-You et al. (1997), Sargeant et al. (2005), Sargeant et al. (2007) and Watling et al. (2012) indicated that learners tended to dismiss feedback from sources that they perceived lacked credibility, often influenced by the feedback generated by the process.
This study supports the view that involving students in self-assessment and peer review practices is important in developing the ability of learners to use and seek feedback (Lefroy et al., 2015).
Learners’ feedback-seeking behaviour in this study highlights a means to enhance the feedback socialisation and exchange of information. We identified factors that learners perceived influenced their feedback-seeking behaviour similar to findings by Delva et al. (2013), such as the development of the feedback exchange culture through peer feedback. The feedback exchange was perceived to be most effective, and promoted engagement following the development of a longitudinal relationship with the feedback provider and when tutors and learners’ goals were aligned (Watling et al., 2014).
Although our learners desire feedback information on how to improve and would like to make a good impression on their tutors, they often hesitated to seek feedback when they perceived their performances had fallen below the required standard. Other factors that affected their quest for feedback included their emotional response to feedback, such as anxiety or incompetence. Learner confidence and the thought of not having adequate knowledge in performing a skill affected receptivity to feedback and feedback-seeking (Eva et al., 2012), so their need to seek feedback motivated them to be better prepared for the clinical skill.
Strategies have been used in the clinical skills laboratory to improve the quality of students’ written feedback comments. Students are told at the start of the module of how much the interaction with their peers may affect their individual learning, while at the same time preparing and encouraging them for daily feedback. They are taught about how they can communicate with their peers. One of the best ways to learn a skill, according to the literature, is to observe a model (Bandura, 1986). The
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teachers, when providing feedback to students, use the same guidelines that they expect students to follow when giving peer feedback e.g. What was done well? What was not done well? And what can be improved? This becomes a good model for students to follow in any feedback situation. Also, teachers’ providing good quality feedback to students on their work is an excellent model for students to provide feedback. This could explain why the difference between the teachers’ feedback rating and the peer written feedback recorded in the third study was minimal (Abraham & Singaram, 2019). At the end of a theme, teachers check logbooks and students are provided feedback on their peers’
feedback. Teachers responded to specific peer comments and suggestions made, by commenting on the characteristics of the feedback that looked helpful or useless. Expectations of good feedback are communicated in the logbook, and students who provided constructive feedback, are commended.
This has the benefit of shaping the students’ feedback-giving skills as well as increasing their motivation to provide feedback next time. The literature indicates that providing multiple opportunities for students to practice feedback is a necessary addition to direct feedback teaching (Svinicki, 2001). Hence, capitalizing on the use of daily peer reviews in the laboratory of clinical skills is an excellent condition for students to practise giving good feedback. The time spent in communicating to students their expectations of constructing feedback during the feedback checks on submission of the skills logbooks, may give students confidence in their ability to handle the peer feedback process effectively. Archer (2010) showed that early training and peer feedback experience in the clinical workplace over time, supports the required cultural change in feedback.
In summary, four inter-related features underpinned the medical students’ feedback literacy skills in the clinical skills learning environment. Students appreciated feedback by recognizing the value of feedback to their learning and more so, understood their important role in the feedback process. Their willingness to make sound academic decisions to strengthen their performance was enhanced through both extended self-evaluation opportunities promoted by regular instructor and peer review practises, and engagement with learning objectives in the clinical skills protocol. Their ability to manage their emotional responses to critical feedback and weak feedback ratings constructively, was recognition that teacher and peer feedback facilitated self-regulated learning and progress. Robinson et al. (2013) mentioned that without providing students with skills to interpret and act on the feedback comments received, only a few students will have the ability to act on feedback. As confirmed in the study, peer feedback and use of the clinical skills protocol as learning and enabling activities in the clinical skills laboratory, maximized the potential for students to take action towards improvement. It offered opportunities for students to receive feedback and act on it. The use of the clinical skills protocol clarified and made assessment expectation goals clear to students, further assisting with their self- evaluation and peer feedback. By teachers communicating the rationale of how the peer feedback and how the skills protocol operate as well as addressing their implications to students’ learning, standards that students’ will have to be constructive in order to benefit from the feedback process were
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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.