A Learning Contract in Clinical Education and Fieldwork
Antwi W. K., Kyei K. A.
Department of Radiography, School of Biomedical and Allied Health Sciences, University of Ghana, Korle-Bu, Accra, Ghana
To cite this article:
Antwi W. K., Kyei K. A.. A Learning Contract in Clinical Education and Fieldwork. Clinical Medicine Research. Special Issue: Radiographic Practice Situation in a developing Country. Vol. 4, No. 3-1, 2015, pp. 31-35. doi: 10.11648/j.cmr.s.2015040301.17
Abstract: Providing feedback to students is a vital skill needed by all clinical teachers. For students to develop and improve their skills in the activity they are involved in, they need to know how they are performing. Providing feedback does not follow that there will be optimal learning. Students should, in the initial stages, be made aware of the desired standard or goal, because it enables them to compare their own performance with the required standard. It is therefore suggested that it should be made known to the learner, some detail of what to do and what they can do in order to improve. Clinical activities of students without feedback could affect their skill training and the patients as well. Proper guidelines should be followed and attention should also be given to those students with learning difficulties.
Keywords: Feedback, Guidelines, Performance, Instructor
Providing feedback to students is a vital skill needed by all clinical teachers (Kaprielian and Gradison, 1998). This is because the prime person to provide feedback to the student is the clinical teacher who is working regularly with the student (Stengelhofen, 1993). For students to develop and improve their skills in the activity they are involved in, they need to know how they are performing (Kaprielian and Gradison, 1998). Giving students feedback of their performance has been found to be an effective way of helping them to progress towards their professional competence in the health professions (Warrender, 1990). Also learners need guidance to improve upon their current level of performance (Qualters, 1999).
Although students are required to direct their own studies and must as well do self assessment, they would need input from experts in their field of study or clinical practice (Kaprielian and Gradison, 1998) to enhance their practice skills. It is the responsibility of clinical educators or supervisors to provide this assistance in the form of continuous feedback (Kaprielian and Gradison, 1998). With regular feedback on frequent basis, students are able to develop self-monitoring skills and ensure that problems do not rear their heads before they are tackled (Stengelholfen, 1993). Providing an effective feedback to learners is therefore an essential part of clinical teaching (Lucas and Stallworth, 2003). Ende (1993) draws on business and psychology literature to provide a classic paradigm of effective feedback. He defines feedback as ‘information that a system uses to make adjustments in reaching a goal’ (Ende, 1983 p.777). The purpose of this essay is to study the methods of providing feedback to students and also receiving same from them. The following paragraphs discuss the achievements in the learning contract.
In order to gain insights into the ways that feedback is given to students, there was an opportunity to meet some allied health professions’ students from the three disciplines (Radiography, Physiotherapy and Occupational therapy (OT). An informal chat with them separately, brought out several issues about feedback. These students shared common views that feedback is very important to them not only from their classroom assessment, but also during their clinical placements. With the exception of the OT who said feedback has always been omitted in their clinical placement, the radiographer always had a written feedback after the placement has been completed whilst the physiotherapist were given oral feedback on the job. All these seem to have their positive and negative side. The written feedback given to the student radiographer according to the student has always been very specific and descriptive however, the only problem is that the feedback takes too long and they (students) tend to forget what they did wrong or right to correct or strengthen the performance. They wished most of the feedback could be prompt and oral.
This is because when it delays, there is the tendency to repeat the bad performance elsewhere before the feedback is received. However, the radiographer was pleased with the discussions that take place on their feedback with the clinical supervisor, which takes place individually rather than in a group. This enables them to explain or discuss other problems which serve as a feedback to the instructor too. The physiotherapist and the radiographer shared the opinion that their feedbacks have been very constructive. The OT felt the lack of feedback was impacting negatively on their activities because they are unable to tell most of the time whether they are on the right path or not. This they feel can have effect on their skills and also on the patients. The students could not create a distinction between feedback and evaluation. They at times consider the whole process as evaluation. The feedback especially to the radiographer has been formal whilst feedback received by the physiotherapy students has been informal.
Researcher’s met with a clinical supervisor of the radiography students who also gave enlightenment on the way they provide feedback to students. The supervisor’s comments were not different from the information provided by the students. However, the issue of being able to observe the activities of the students during their clinical activities was stressed if you will be able to provide an effective feedback. Also according to the instructor, by discussing the student performance in their feedback they also get feedback from them which enable reflections on the way the clinical supervision goes on and if there is the need to change anything, it is discussed with the visiting clinical instructors of the students to effect change. Having had this information about feedback in the clinical setting, the literature was also searched. This was to find out what has been said and how they blend with the sentiments of the students and the clinical supervisor discussed above and how it addresses the learning needs as stated on the contract form. The following paragraphs discuss the literature under the following headings: the nature of feedback, types of feedback, feedback and evaluation, feedback to problem learners, clinical education without feedback, and guidelines for giving feedback.
1.1. The Nature of Feedback
According to Ende (1983) the idea of feedback-information, that a system uses to make changes to attain a goal, was first initiated by rocket engineers in the 1940s and has since been used in many areas including its application later in humanities. Ende (1983) further states that feedback is the control of a system by putting back into the system the results of its performance. He contends that, if, however, the information which proceeds backwards from the performance is able to effect change in the general method and pattern of the performance, the process achieved could as well be called learning. The use of feedback and its importance in the clinical setting, to acquire clinical skill, follows from the nature of the clinical method (Ende, 1983).
Clinical skills combine cognitive, psychomotor, and effectual behaviours and like a ballet, it is best learned in front of a mirror (Ende, 1983) and also like playing darts you get better when you are able to see where the darts land (Gibbs, 1999). Good practice which encourages active learning is about the role of feedback that students need in order to learn (Gibbs, 1999). Good practice therefore gives prompt feedback (Gibbs, 1999). Learners actively demand effective feedback that is timely and specific about behaviours that can be changed (Schum and Krippendorf, 2000) and good performance that can be reinforced (Ende, 1983).
Feedback has a source from formative assessment which in itself is founded on the principle of maximizing learning (Stuart, 2003). Information gathered from the assessment about the student’s knowledge, understanding and skills are used to feedback into the teaching and learning process (Gripps, 1994). The content and quality of feedback are both vital as stressed by Sadler (1989). Sadler had observed that improvement in students is not automatic when teachers in the mainstream education provide valid and reliable judgments about student’s work. Providing feedback does not follow that there will be optimal learning (Stuart, 2003). Students should, in the initial stages, be made aware of the desired standard or goal, because it enables them to compare their own performance with the required standard (Stuart, 2003). It is therefore suggested by Stuart that it should be made known to the learner, some detail of what to do and what they can do in order to improve. According to Bailey (1998), students should be motivated to come out with what they want feedback on because this has been found to enhance the development of self awareness of personal and professional development. This could also help to provide specific feedback which is more acceptable than non-specific feedback.
Feedback which is non-specific becomes increasingly unhelpful to the student as the volume and diversity of performance being assessed keep on mounting (Rowntree, 1987). This is truer with the practice of radiography where changing technology and examinations performed, keep on adding up. For example, performing the X-ray of a simple hand to interventional procedures, the activities differ. Therefore what is required of the student should be made known in order to provide specific and useful feedbacks. Stengelhofen (1993) also suggest that when a planned programme for the duration of students’ placement is organised, on an identified occasion, feedback can be focused on work either of a specific case or on the student’s progress with certain clinical competencies.
Planning this in advance will speed up the student’s learning. Freeman and Lewis (1998) have stated that it is essential for clinical supervisors or teachers to find out from students how helpful their feedbacks are to them and how is might be improved in the future.
Students can therefore be asked collectively or individually, according to them, to:
Find one or more examples of feedback comments they found helpful
Explain how they helped.
Find one or two examples of feedback comments which they found unhelpful
Explain why these were unhelpful
Say what they will welcome in future.
This kind of exercise serves two purposes in the view of Freeman and Lewis (1998).
First it alerts students to the importance of considering and using feedback. Second, it gives the clinical instructor the information needed to reflect on in the practice.
1.2. Types of Feedback
Branch and Paranjape (2002) classifies feedback into three different forms. These are Brief feedback, Formal feedback and Major feedback. They explain that brief feedback is the type that one might provide while demonstrating the physical examination or during someone’s presentation of a patient’s history. According to them, brief feedback disciplines the instructor to provide strong and useful suggestions. As example would be "Let me demonstrate to you a better way to position the lateral knee". If this specific teaching interventions are preceded by the phrase, "Let me give you feedback" they become brief feedback (Branch and Para jape, 2002). Formal feedback is given when a time is set and labelled as formal feedback to deliver an important feedback to the learner (Branch and Paranjape, 2002).
They site an example that a formal feedback can be given after an encounter with a clinical procedure or when there is a clinical mistake on the part of the supervisee. There is a contrasting view about formal feedback. Henry (1985) in his contribution to feedback in the clinical setting also state that feedback can be formal or informal. However in explaining formal feedback, he said it is a communication which is in the form of a written document such as the one provided to the radiography student stated above. Informal feedback also in his view is provided in the form of an oral communication, tone of voice, body language and other forms of non verbal behaviours which usually is non judgemental. Branch and Paranjape (2002) did not make it clear whether formal feedback is necessarily a written communication handed over to the student for discussions.
However, they suggest that to elicit self feedback from the learner, the instructor under formal feedback can say to the student "How did this encounter go for you?" and proceeding to "what went well and what could have been done better". This implies that formal feedback should not necessarily be in a written form for future discussions after the student has completed the placement or the clinical rotation. The third category of Branch and Paranjape’s feedback is the major feedback. This involves scheduled sessions to give feedback at the midsection of a learning experience (Branch and Paranjape, 2002) such as being assigned to barium meal investigation or any clinical procedures. These sessions according to them are supposed to last between 15 to 30 minutes and should be held in private. This allows the student to become aware that feedback will be given which gives him or her chance to reflect on performance. It has also been found that major feedback is conducive to midpoint corrections, which may also apply to addressing major issues, such as inadequate performance or unprofessional attitude (Branch and Paranjape, 2002).
The style of feedback can be oral or written because students accepts and need both (Stuart, 2003). However Fish and Twinn (1997) are of the opinion that having a written communication serves as an essential document that provides continuity in the tracking of students progress. It has also been stated that it is easy to keep written notes which also prevents forgetfulness and maximises the ability to learn (Bailey, 1998). Although written feedback has been suggested, the other side of it is that students will not be able to respond immediately with any queries or problems. In these circumstances you cannot check quickly and easily the impact of what has been written (Rowntree, 1991). Providing constructive feedback has also been likened to a sandwich (Dolley et al 1998). They state that providing constructive feedback should be like a sandwich with the negative feedback is not easy, (Dohrenwend (2002) also share the sandwich view that, sandwiching criticism between layers of praise makes it more palatable and more effective. This helps to maintain students’ morale and strengthens performance (Driscoll, 2002).
1.3. Feedback and Evaluation
Feedback and evaluation are all integrated parts of every day communication that instructors and supervisors use to help students and workers to learn and grow (Henry, 1985). Providing true feedback is not easy because it has been confused with judgments made during evaluation (Ende, 1983; Henry, 1985). Feedback is formative and provides information devoid of any judgements compared to evaluation which is also summative (Ende, 1983). Evaluation because it comes after the fact, presents usually the instructor’s judgement about how well or badly a student attained a given goal, in relation to the performance of other student colleagues (Ende, 1983). Moreover, according to him evaluation is usually stated in a normative language which is full of adverbs and adjectives, whilst feedback is neutral in that it is composed of verbs and nouns. However, it is still difficult to totally disallow judgements assigned to feedback information (Ende, 1983). For example there is simply no way that you can inform the learner that a radiation protection measures were not taken care of in performing a particular investigation that requires radiation protection. This invariably may cause embarrassment.
It does not mean that such information should not be to the attention of the student. The most important thing according to Ende is to do it with some skill and understanding of the process. Feedback allows a choice on the part of the learner or receiver and also contains more specificity than evaluation because; it is reporting facts (Henry, 1985). Evaluation although make use of facts, as a basis for opinions, these facts are most often not directly expressed (Henry, 1985). He also belief that the reason behind students confusing evaluation with feedback is that when the communication is factual, but the tone of voice is judgemental, the confusion sets in. Henry failed to address his written communication in the formal feedback, how these two clinical assessment tools pose misunderstanding.
1.4. Feedback to Problem Learner
Several literatures studied failed to consider this class of students who are also found in the clinical setting. However, Lucas and Stallworth, (2003) suggests some tips for providing feedback to problem learners. These are learners whose performance is below their potential because of some specific difficulties (Lucas and Stallworth, 2003). According to them handling problem learners is not easy and it is very challenging when providing them with assistance and effective feedback of their performance. However, to them it is rewarding when the clinical instructor is able to provide early and caring intervention to such learners. They further suggest that as a first step, one need to type and specify the ineffective behaviours and redirect these behaviours.
Moreover, Lucas and Stallworth (2003) states that by giving a more detailed description about ineffective behaviors the clinical instructor creates an opportunity for the learner to respond and a sense of how to improve. The next step is to identify the category of difficulty experienced by the learner. The importance of this is that to help the learner will depend on the accurate assessment of the learner’s difficulty. Once this has been done, feedback is best provided using the concept of "perception versus reality" (Lucas and Stallworth, 2003). In this concept, the instructor describes how he or she perceives about the learner’s behaviour but should understand that the learner may have a different opinion about his or her actions (Lacus and Stallworth, 2003). They conclude that once feedback has been given, there must be a strategy for treatment and follow up.
1.5. Clinical Education Without Feedback
The reason for clinical training is to develop expertise in the care of patients (Ende, 1983). He contends that lack of feedback will mean poor performance or mistakes will go uncorrected and good performance will also not be strengthened. It will also create the platform for clinical competence to be achieved empirical or not all (Ende, 1983). Like the sentiments of the OT discussed above, clinical training without feedback will result in students having their sense of going wayward in an unknown environment increased (Ende, 1983). The consequences of not providing feedback will endanger patients that students handle in the clinical setting and moreover can go beyond their clinical training such as when qualified and sent out to practice on their own.
A bad habit might be taken into the real world when learners became full blown experts. It also implies that clinical teachers or supervisors are not going to get any useful information from students to diagnose their own teaching. Insofar as the clinical activities reveal strengths and weaknesses in the student’s learning the supervisor may be able to recognize where he or she has failed to explain a new concept, confused an issue, given insufficient practice and so on (Rowntree, 1991). Moreover, in his view, feedback to the clinical teacher may also help to modify teaching or the supervision for the benefit of subsequent students. Feedback therefore is a two way process which is vital in clinical teaching and learning (Freeman and Lewis, 1998).
2. Guidelines for Providing Feedback
Berguist and Phillips, (1975;) Morgan and Irby, (1978;) Ende, (1983;) Schwenk and Whitman, (1987;) Weinholtz and Ewards, (1992;) Stengelhofen, (1993;) Westberg and Jason, (1993;) Stuart, (2003) share common views in providing effective feedback. They suggest the following as guidelines for providing feedback effectively.
1 Learners should be assisted to turn negative feedback into constructive challenges
2 The highest priority should be the first to start with to prevent overloading the learner with extensive feedback
3 In providing feedback on a particular incident the clinical teacher should be sure of having all the facts and /or both sides of the story.
4 There should be follow up in feedback given to learners.
5 Communication should be clear, specific, direct and non-judgemental.
6 Solutions to issues and problems should be in mind beforehand.
7 The feedback should be well planned and timed. It is not appropriate to provide feedback when either the instructor or student is stressed.
8 Feedback should be provided in a spirit of care and concern within an environment where mutual trust prevails.
9 Learners should be asked about their own views concerning their performance and also relate the feedback to the learner’s sated goals.
10 The feedback should be descriptive rather than evaluative whilst paying attention to behavior and performance rather than making generalized statements.
Feedback to students is very essential during their clinical placement or rotation. For it to be effective it should be as prompt as possible. It can either be in written or oral communication. Clinical activities of students without feedback could affect their skill training and the patients as well. Proper guidelines should be followed and attention should also be given to those students with learning difficulties.