How to give and receive constructive feedback

Feedback has been described as the “cornerstone of effective clinical teaching”^[1]
and can help pharmacists develop their clinical skills in a real-world environment^[2],[3],[4]
.

Pharmacists are required to deliver and receive feedback in a variety of formal and informal contexts. This may be as part of an appraisal or assessment; a particular aspect of work, such as punctuality, behaviour towards colleagues or patients; or on a presentation or manuscript. Pharmacists may also be required to deliver feedback to other healthcare professionals — for example, if a doctor has prescribed something inappropriately^[5]
, is not acting on medication-related jobs, or repeatedly sends discharges late to the pharmacy.

Positive (reinforcing) and negative (corrective) feedback has many benefits^[6]
and is considered central to supporting cognitive, technical and professional development^[7]
where the aim is to reduce the gap between actual and desired performance^[8]
. Without feedback, individuals may have false perceptions of their performance. Delivered effectively, feedback can motivate, raise self-awareness, identify learning needs, help individuals fulfil their potential, and encourage feedback-seeking behaviour^[1],[6],[9]
.

Feedback has an important role in the learning cycle^[10]
. Experiential learning theory^[11]
suggests that learning occurs cyclically (see ‘Kolb Cycle’). There are four key stages, typically commencing with an individual task or experience (concrete experience). This is followed by reviewing or reflecting on that experience (reflective observation), processing ideas and concluding from the experience (abstract conceptualisation) and finally committing to action to plan and try out new ideas (active experimentation). The cycle should then be restarted to review the effect of those changes and new experiences. This underpins the familiar continuous professional development cycle of reflection, planning, action and evaluation. Feedback can support individuals in progressing through this cycle by cultivating reflection at each stage^[12]
.

Kolb Cycle

Defining feedback

There are various definitions of feedback within organisational and educational literature. Within education, feedback has been described as “information describing… performance in a given activity that is intended to guide… future performance in that same or a related activity”^[13]
.

Feedback is considered most effective when it is constructive^[14],[15]
and is not simply praise — “that was excellent” — or criticism — “you always do this wrong” — which are personal judgements and can be destructive^[6],[14]
. To be constructive, feedback should provide specific, objective information on a particular task that the recipient can use and builds on strengths as well as identifying strategies for improvement^[16]
. Provision of constructive feedback is a skill that requires practice^[17]
but can be learnt and supported by adopting some simple rules.

Delivering feedback

Whether delivering formal feedback at appraisals or informal feedback on the ward or in the dispensary, there are some simple principles and tips that can be followed to enable effective feedback^{[7],[14],[18],[19],[20]}
.

Recipients should be engaged with directly and the process should not be sugar-coated. If you are preparing to give feedback, get straight to the point in your first sentence by saying “I want to talk to you about… When would be a good time to talk?”

Feedback should then be delivered in a suitable environment. It is important to ensure the interaction is private, especially when delivering negative feedback, to prevent embarrassing the recipient. In addition, to ensure that feedback promotes learning and is “received mindfully”^[21]
, it should be timely to facilitate memory recall, and received when the recipient is focused on the feedback session and not on other distracting tasks^[5]
.

Any feedback session should be a dynamic, interactive conversation to facilitate learning^[22]
and has been described as an educational alliance^[23]
— it must not be a passive process where the recipient does not respond^[7]
. To encourage recipients to reflect on their own performance, the facilitator can use open questions such as “How do you think you performed today?” or “How do you think that counselling session went?”

If negative feedback must be delivered, it should be balanced with positive feedback to encourage further exemplary behaviour^[18]
. For example, opening with “You correctly addressed and resolved the medication issues A, B, C for [patient name], and I also observed that you did not address X, Y and Z”. This approach is likely to motivate the individual and make them more likely to accept the negative feedback^[1]
and actively seek further feedback^[24]
. In instances where poor performance is identified, encouraging reflection on the performance with open-ended questions such as “How do you think that went?” can identify any causative factors of which you may be unaware and will inform later goals and action plans. Feedback should not overload or overwhelm learners and should focus on two to three areas of development^{[4],[24],[25]}
.

Using “I” instead of “you”, maintains objectivity
^[17]
, for example, saying “I have observed that…” as opposed to “you haven’t done…” provides specific examples to work with and avoids the feedback being received as a personal attack, general opinion or hearsay. If you have not directly observed a behaviour but have received a report from another individual then you could say “I have received a report about…” so that you still own the feedback^[25]
and you are therefore not passing on somebody else’s opinion. Facilitators should choose their language carefully and avoid generalisations such as “you always do this” or “you never do that”. This will maintain the focus on the behaviour or performance that is being discussed, as opposed to the individual’s character. This can be supported further by the facilitator providing specific examples of good or poor practice to contextualise any message and highlight expected standards to the recipient.

Feedback should conclude with agreed solutions and action plans that are identified by the recipient or negotiated by the facilitator, with some guidance offered as a strategy for improvement, especially for negative feedback. This can be achieved by asking: “What could you do differently next time?” or “Have you thought about doing it this way?”

Additionally, checking understanding reinforces that the session is about the recipient’s development. Seeking clarification of their understanding gives the recipient the opportunity to inform you of their planned behaviour. This can be encouraged by asking open-ended questions such as “So the next time you are faced with [a similar situation], what will you do differently?”

Feedback models

Several feedback models, such as the sandwich method^[26]
, Pendleton’s rules^[27]
and BOOST^[28]
, are described in literature, although no single approach is considered most effective^[20]
. The approach that is adopted is likely to be dependent on the facilitator-recipient relationship and the situation, emphasising the need for flexibility and a culture of trust and respect.

The sandwich model consists of negative feedback ‘sandwiched’ in-between positive feedback, with the facilitator outlining what went well, what can be improved and then closing with what went well. While this is constructive, it does not always lend itself to two-way communication, meaning that there is a risk that the feedback becomes facilitator-led. Additionally, recipients may anticipate the transition to ‘but’ and miss the positive message^[14]
. This can be avoided by being sincere and wording feedback carefully, for example, “Your presentation was clear and audible with good use of audio-visual aids and I observed one area that could be improved.”

Pendleton’s rules consist of asking the student what went well, telling them what went well, asking them what can be improved and then telling them what can be improved. This approach encourages reflection and self-assessment and is well balanced, but is also a rigid and formulaic approach for what should be a dynamic process.

BOOST^[28]
describes delivering feedback that is balanced, observed, objective, specific and timely. ‘Balanced’ feedback focuses on strengths and weaknesses to reinforce good behaviour and support development. The model also requires that feedback is given on what has been ‘observed’ or for which evidence is available, and that it is ‘objective’, avoiding personal judgements and focusing on the task or behaviour in a descriptive, rather than evaluative, manner. ‘Specific’ refers to providing examples of good or poor practice and avoiding vague generalisations such as “always”. Finally, the feedback should be given in a ‘timely’ manner to ensure that the event can be recalled easily and the feedback is still relevant. However, again, this model may not easily facilitate two-way interaction.

When used correctly, these models can support delivery of feedback to make it a more consistent and effective experience for recipients. By encouraging recipients to identify their own strengths and weaknesses, the facilitator is able to listen actively and provide relevant examples and targeted solutions where appropriate^[29]
.

Receiving feedback

There is potential for feedback to be received poorly, even when delivered constructively, creating anger, denial, blame or rationalisation^[16],[30]
. The facilitator should remain positive and follow the above principles with specific examples, linking observed behaviour with performance standards and showing empathy to recipient’s feelings. Suggestions to facilitate effective receipt of feedback are provided in ‘Box 1: Hints on receiving feedback’.

Following feedback

Informal feedback can be opportunistic but where it forms part of ongoing or formal performance reviews, timescales for completing action plans or engaging with learning opportunities should be agreed and, where relevant, follow-up sessions organised for further receipt and delivery of feedback. This can allow progress review towards the desired outcomes or performance standards^[18]
. Finally, any relevant documentation should be completed with copies kept by both parties. Both parties should also reflect on the session to improve or ensure continued successful feedback.