How my students do case studies in clinical practice

Our students do small case studies as part of their clinical practice rotations. The basic idea is that they need to identify a problem with their own practice; something that they want to improve. They describe the problem in the context of a case study which gives them a framework to approach the problem like a research project. In this post I’ll talk about the process we use for designing, implementing, drafting and grading these case studies.

There are a few things that I consider to be novel in the following approach:

  1. The case studies are about improving future clinical practice, and as such are linked to students’ practices i.e. what they do and how they think
  2. Students are the case study participants i.e. they are conducting research on themselves
  3. We shift the emphasis away from a narrow definition of “The Evidence” (i.e. journal articles) and encourage students to get creative ideas from other areas of practice
  4. The grading process has features that develop students’ knowledge and skills beyond “Conducting case study research in a clinical practice module”

Design

Early on in their clinical practice rotations, the students identify an aspect of that block that they want to learn more about. We discuss the kinds of questions they want to answer, both in class and by email. Once the topic and question are agreed, they do mini “literature” reviews (3-5 sources that may include academic journals, blogs, YouTube videos, Pinterest boards…whatever) to explore the problem as described by others. They also use the literature to identify possible solutions to their problems, which then get incorporated into the Method. They must also identify what “data” they will use to determine an improvement in their performance. They can use anything from personal reflections to grades to perceived level of comfort…anything that allows them to somehow say that their practice is getting better.

Implementation and drafting of early case studies

Then they try an intervention – on themselves, because this is about improving their own practice – and gather data to analyse as part of describing a change in practice or thinking.  They must also try to develop a general principle from the case study that they can apply to other clinical contexts. I give feedback on the initial questions and comment on early drafts to guide the projects and also give them the rubric that will be used to grade their work.

Examples of case studies from last semester include:

  • Exploring the impact of meditation and breathing techniques to lower stress before and during clinical exams, using heart rate as a proxy for stress – and learning that taking a moment to breathe can help with feeling more relaxed during an exam.
  • The challenges of communicating with a patient who has expressive aphasia – and learning that the commonly suggested alternatives are often 1) very slow, 2) frustrating, and 3) not very effective.
  • Testing their own visual estimation of ROM against a smartphone app – and learning that visual estimation is (surprise) pretty poor.
  • Exploring the impact of speaking to a patient in their own language on developing rapport – and learning that spending 30 minutes every day learning a few new Xhosa words made a huge difference to how likely the patient was to agree to physio.

Submission and peer grading

Students submit hard copies to me so that I can make sure all submissions are in. Then I take the hard copies to class and randomly assign 1 case study to each student. They pair up (Reviewer 1 and 2) and we go through the case studies together, using the rubric as a guide. I think out loud about each section of the rubric, explaining what I’m looking for in each section and why it’s important for clinical practice. For example, if we’re looking at the “Language” section I explain why clarity of expression is important for describing clinical presentations, and why conciseness allows them to practice conveying complex ideas quickly (useful for ward rounds and meetings). Spelling and grammar are important, as is legibility, to ensure that your work is clearly understandable to others in the team. I go through these rationales while the students are marking and giving feedback on the case studies in front of them.

Then they swap case studies and fill out another rubric for the case study that their team member has just completed. We go through the process again, and I encourage them to look for additional places to comment on the case study. Once that’s done they compare their rubrics for the two case studies in their team, explaining why certain marks and comments were given for certain sections. They don’t have to agree on the exact mark but they do have to come to consensus over whether each section of the work is “Poor”, “Satisfactory” or “Good”. Then they average their marks and submit it to me again.

I take all the case studies with their 2 sets of comments (on the rubric) and feedback (on the case study itself) and I go through them all myself. This means I can focus on more abstract feedback (e.g. appropriateness of the question, analysis, ethics, etc.) because the students have already commented on much of the structural, grammatical and content-related issues.

Outcomes of the process

For me, the following outcomes of the process are important to note:

  1. Students learn how to identify an area of their own clinical practice that they want to improve. It’s not us telling them what they’re doing wrong. If we want lifelong learning to happen, our students must know how to identify areas for improvement.
  2. They take definite steps towards achieving those improvements because the case study requires them to implement an intervention. “Learning” becomes synonymous with “doing” i.e. they must take concrete steps towards addressing the problem they identified.
  3. Students develop the skills they need to find answers to questions they have about their own practice. Students learn how to regulate their own learning.
  4. Each student gets 3 sets of feedback on their case study. It’s not just me – the external “expert” – telling them how to improve, it’s their peers as well.
  5. Students get exposed to a variety of other case studies across a spectrum of quality. The peer reviewers need to know what a “good” case study looks like in order to grade one. They learn what their next case study should look like.
  6. The marking time for 54 case studies goes down from about 10 hours (I give a lot of feedback) to about 3 hours. I don’t have to give feedback on everything because almost all of the common errors are already identified and highlighted.
  7. Students learn how I think when I’m marking their work, which helps them to make different choices for the next case study. This process allows them access to how I think about case study research in clinical practice, which means they are more likely to improve their next submission, knowing what I’m looking for.

In terms of the reliability of the peer marking and feedback, I noted the following when I reviewed the peer feedback and grades from earlier in the year:

  • 15 (28%) students’ marks went up when I compared my mark with the peer average, 7 (13%) students’ marks went up by 5% or more, and 4 (7%) students went from “Fail” to “Pass”.
  • 7 (13%) students’ marks went down, 3 (6%) by 5% or more, and 0 students went from “Pass” to “Fail”.
  • 28 (52%) students’ marks stayed the same.

The points I take from the above is that it’s really important for me to review the marks and that I have a tendency to be more lenient with marking; more students had mark increases and only 3 students’ marks went down by what I would consider a significant amount. And finally, more than half the students didn’t get a mark change at all, which is pretty good when you think about it.

 

 

Principles of learning

World_Cyber_Games_2004_AuditoriumI’ve been cleaning up my office over the past few days and came across a handout that I probably received at a T&L workshop sometime during the past year, and thought I’d post a summary of it here. There is a link on the document to this online version, although the hard copy that I have has different content under the same headings. Developing learning activities that try to take into account the following principles is more likely to result in deeper learning. Note: I couldn’t help but think about how video games incorporate all of these principles, which says a lot about a) what the gaming and entertainment industries know about engagement, and b) how boring a lot of classroom activities must be for students.

  1. Prior knowledge can help or hinder learning. How we mis/understand information changes how we perceive new information. If our prior knowledge is incorrect or incomplete, it affects how we understand new things. Teachers must therefore ensure that students articulate prior knowledge, in order to correct or consolidate it.
  2. Motivation generates, directs, and sustains learning behaviour. Our interests, goals, expectations, beliefs and emotional responses directly influence how much time and effort we devote to learning.
  3. The way students organise knowledge determines how they use it. When representations of knowledge are accurately formed, we’re better able to store and retrieve new information. When knowledge is organised according to superficial features, or when the relationships are inaccurate, or when the representation is of disconnected and isolated facts, we are more likely to incorrectly organise new information.
  4. Meaningful engagement is necessary for deeper learning. Meaningful engagement leads to the formation of more connections between concepts. The more connections that exist between concepts, the more likely it is that we will be able to retrieve and use those concepts as tools, instead of having them exist as isolated facts. Examples of meaningful engagement include asking (and also answering) questions, making analogies, and using knowledge to solve problems, lead to longer lasting and stronger representations of knowledge.
  5. Mastery requires developing component skills and knowledge, synthesising, and applying them appropriately. Performance of complex tasks (e.g. writing) is composed of many interrelated but discrete component skills. In order to gain mastery of the complex task, we must first practice and gain proficiency in the component skills, and then organise and itnegrate them into a coherent whole. These new skills must also be practiced in different contexts, which enables us to transfer the skills from one place to another.
  6. Goal-directed practice and targeted feedback are critical to learning. Learning is enhanced when we work towards a specific level of performance and regularly evaluate our progress against a clearly defined goal. Feedback should explicitly relate performance to the goal criteria, should be timely, frequent and constructive, and there must be opportunities to use the feedback in future activities.
  7. Students must learn to monitor, evaluate and adjust their approaches to learning to become self-directed learners. We must learn to be conscious of our own thinking process (metacognition). We should help students monitor, evaluate and reflect on their own performance, and provide feedback on their progress. Teachers must also model their own thinking and reasoning strategies for their students.
  8. Because students develop holistically, their learning is affected by the social, emotional and intellectual climate of the classroom. We are all intellectual, social and emotional beings and any learning activity needs to take all of these dimensions into account. The social and emotional aspects of the environment will influence the learning process. For example, in trusted settings, we may be more likely to take creative risks, whereas if we fear ridicule we are more likely to disengage from the process completely.

Note: I wrote a similar post earlier in the year, on the theoretical underpinnings of problem-based learning, which has some of the same ideas, as well as an even earlier post on the principles of authentic learning.

Strategies to improve clinical teaching: a workshop

Photo from paukrus on Flickr

On Saturday I attended a workshop at Groote Schuur hospital that had the aim of providing “…clinicians with the opportunity to improve their ability to facilitate learning in clinical practice”. Objectives included improving the understanding of theories of learning, methods of enhancing learning and assessment practices and the role of assessment in learning. I was impressed with the number of clinical educators and supervisors (about 40) who gave up their Saturdays to attend. Here are my notes:

Learning in clinical practice

Brainstorming:

  • How do I learn? Immersive, pulling in additional material, alternative ideas, I need to see the big picture
  • How do I learn best? Personal, vested interest, answering a question of relevance, application to a relevant problem, can be associated with different sensory modalities
  • How did I develop “expertise”? Socially, conversation, discussion, sharing, questioning, choosing to “own” something, pushed out of your comfort zone
  • How does learning happen? Reducing to basic principles, commitment, dedication
  • When last did you learn something new?

Students feel lost and disorientated when first arriving on a placement, no matter how much they prepare, they still feel unprepared

Theory is linear, it’s neat and “tight”, whereas practicals are messy and untidy. So, theory doesn’t prepare you for practice, only practice does

Students should be allowed to make mistakes, but when a patients health and well-being are at risk, mistakes are problematic. Students want to be “right” (maybe because we stress how important it is that they get it “right”). Clinical skills labs are useful to address the problem of practising and being allowed to make mistakes. But clinical skills labs are expensive

“Learning” is the process of turning information into knowledge through engagement

Learning is about making meaning

Students struggle with theoretical concepts until they have the opportunity see / feel the concept in the real world e.g. low tone, ataxia

Learning happens by linking new ideas to older, established ideas, which is why our perceptions of the world are highly individual

What do we do to develop student, as well as professional identity. The notion that students are “socialised” into the profession

Once students cross a “threshold”, the learning experience opens up to them

Students sometimes know the words, but not what they mean

Many students have trouble navigating between different professional contexts

Reducing power differentials helps students feel at ease and more comfortable with the idea of sharing ideas / themselves, you “humanise” the interaction

Students often don’t have a framework for self-evaluation i.e. they don’t know what a 3rd year should be able to do relative to a qualified practitioner. Their frame of reference is limited to themselves and a few teachers whose thinking process exists inside a black box

Correct errors gently, create a space of emotional safety, learning doesn’t happen in an emotional / financial / social / personal vacuum (in another workshop that I attended the other day, the presenter mentioned the “kind teacher”, an idea that I’ve been thinking about a lot)

Predicting the future by understanding the past allows us to look back at our practice and make long term plans for patient management

Enhancing learning in clinical situations

Why is the clinical learning situation so unique? Good place to apply theory, real world scenarios, BUT also a place that can inspire levels of fear that are not present in a classroom

We can ask students to assess their fears i.e. what are they afraid of and why. Then create an environment in which they can confront their fears and see the outcomes of their fears realised e.g. take off the cardio leads and hear the alarm go off, but also see that the patient continues breathing

Educational theories and frameworks can give students a structure for thinking, can help guide their thought processes, but do they necessarily need a deep understanding of the theory e.g. social constructivism?

Creating relationships between pathology and “normal” helps students understand dysfunction. However, this does little to help them develop a management protocol i.e. relate dysfunction to intervention

Facilitating ethical reasoning in student clinical practice. The relationship between ethical principles should be analysed in the light of their impact on the patient

In the early stages of their training, students don’t yet have the language to articulate ethical dilemmas

Feedback to students around ethical dilemmas should acknowledge the experience, but not pass judgement on any of the parties involved

Students often don’t emphasise the moral and ethical components of their practice, as they believe that technical ability is what they will be assessed on (which is true)

Assessment isn’t perfect

Use rubrics to prepare students in terms of providing a framework for their learning

Students won’t expose their weaknesses if they believe that they will be judged on them

Students must be able to act on the feedback given, which means that it must be timeous in order to be relevant

Students need to “learn how to know”

Basic presentation skills for postgraduates

A few weeks ago I gave a presentation to our postgraduate students who were preparing to submit their Masters proposals. One of our requirements in the department is that any student wanting to submit a proposal must present to the the department for critical feedback. We want our proposals to be as strong as possible when they serve at our faculty Higher Degrees committee. Many of our postgraduate students come from other African countries, and very often have formally presented before. I was asked to give a short presentation giving them a few tips on academic presentations.

I wanted to step out of the linear, bullet point style of presenting that Powerpoint defaults to, so decided to try Prezi for a change. I’d played around with it a few years ago but struggled with the interface. This time I found it more agreeable and enjoyed playing around with it. It is a bit all over the place and the spacing doesn’t always work but anyway, here’s the presentation:

Facebook, friends and students

This is post is the first of what I hope will be several reflections on the softening boundaries between my social and professional lives, and how they influence each other. When I started teaching in the department about 3 years ago, I decided that I wouldn’t accept friend requests on Facebook from any of our students, nor would I send them any. I had a few reasons for this, including the following beliefs:

  • It’d be an invasion of their privacy
  • They may feel an obligation to accept, even if they didn’t want to
  • I didn’t feel comfortable hearing and seeing what they were doing in their private lives
  • I wasn’t sure that I’d be able to remain objective if I grew closer to the students I shared interests with
  • I was trying to keep my professional and private lives separate

Last year I ran a social networking research project in our department, which had students completing assignments within a private social network that I set up using WordPress and Buddypress. I learned a lot through the experience, including the following:

  • Facilitating engagement around professional issues in a social environment is hard
  • Students use (or don’t use) the tools in the way you expect / want them to
  • Most of them only participated in the network for the duration of the assignment, and didn’t go back when it was completed
  • Students shared personal experiences (with me and with each other) in ways that helped me to see more clearly who they really are

The last point was perhaps the lesson that touched me most. Most of our students have a tendency to see us as “just lecturers” and feel that there’s a huge chasm between us and them. To get around this, I often share some of my personal experiences to show that I also struggle to get through the challenges I’m presented with. I try to highlight the fact that as they find some things difficult to overcome, so do I and that the only real differentiator between us is our levels of experience in the various domains of our lives. This has happened most often with students on one of the rural community placements that I supervise. I often spend hours talking to them about some of the issues they’re experiencing, not only on the placement, but also in their personal lives. This has had a profound impact on some of them, as they’ve come to me after graduating and told me how much those social interactions helped shape who they’ve become.

I’m beginning to think that it’s impossible to keep my personal life out of the classroom and in addition, whether that’s something I should even strive for. The end of last year saw me going through an emotional upheaval that was devastating. I was incapable of thinking clearly, let alone teach (thankfully, classes were over for the year) and it was clear that my personal experiences very much affected my professional behaviour. This got me thinking about what our students bring with them into the classroom that we have no idea of, and which has a profound impact on how they’re able to participate in the class. What I’ve learned through this is that my social and professional personas are not only connected, but deeply integrated and to ignore that is to miss out on really understanding myself and my students.

I’ve also been more active on Facebook recently. Over the past month or so, I’ve been friending last years graduates as they prepare for their year of community service in different parts of the country. Not only do I enjoy keeping in touch with them, I try to provide an additional level of support as they’re trying to find their way in their professional lives. This has been an interest of mine since my Masters research looked at how emerging technology could be used to help support students and new graduates, especially in the more rural placements. This is the second year that I’ve been adding our past students to my Facebook friend list, and I often have opportunities to catch up with how they’re getting on, which is great.

This, together with my social networking project, has had me reflecting on whether or not maintaining the “friend barrier” with students on Facebook is actually a good thing. My understanding of what is “personal” and what is “professional” is that they’re blurring together, and I wonder if exploring different aspects of engaging with students on Facebook might be a positive experience for us all. A simple example would be the many opportunities for modeling behaviour. Instead of having a “No Facebook-friending” policy, wouldn’t it be better to tell them that I’m available on Facebook if they’d like to connect? I could tell them that there’d be no pressure to ask or accept and that they wouldn’t be disadvantaged by choosing not to do it (for example, I won’t be giving exam tips on Facebook). I’d also make it clear that for good or bad, I’d be able to see their social activities (as they’d be able to see mine), which may impact on our classroom interactions.

Our 4th year students spend most of the year off campus on clinical placements, and often feel that they’re isolated from social and professional support. I’m thinking of letting them know that if they send me a friend request, I’ll accept it, having first run through the implications of what it’d mean. If you have any thoughts or suggestions, I’d love to hear from you.

Twitter Weekly Updates for 2010-08-30

Posted to Diigo 08/01/2010

xWeb « Connectivism Annotated

  • Naming things is important. It’s easier to say “web 2.0″ than “participative, fragmented content, conversation-driven web”. Unfortunately, names give shape to concepts that are often imprecise. Sometimes words hurt more than they help.
  • xWeb is the utilization of smart, structured data drawn from our physical and virtual interactions and identities to extend our capacity to be known by others and by systems. This is an imprecise definition, but it’s a start
  • It involves a negotiation of two key questions that I continue to grapple with:

    1. What does technology do better than people?

    2. What do people do better than technology?

With xWeb, we are rethinking what we have to do as people and starting to rely on what technology does better than we possibly could. Over the last few years, I’ve been trying to capture the nature of the change around technology. Some of the recurring themes:

  • augmentation
  • aggregation
  • semantic web
  • location-based services (geoweb)
  • data overlaya
  • smart information
  • visualization
  • social media
  • open data and data in general
  • Internet of things
  • cloud computing
  • mobile technologies
  • analytics and monitoring
  • And, to that list, we could add filtering, recommender systems, distributed “like this” tools, annotation tools (diigo), wearable computing, and so on
      • Web 1.0 mainly seemed to consist of semantics, Web 2.0 of connections, communications, multi-media, virtual worlds and the introduction of mobile devices through the emergence of wireless and higher Internet connection speeds; while Web 3.0 connects data streams in a supposedly intelligent way. The combination of all four would lead to Web X.0 (Steve) or Web X (Stephen)
      • Why would anybody need some researchers and developers to work on a PLE for them?
      • 1. Intelligent data connections are one exciting option for PLE development and networked learning. Recommender systems of information, resources, critical friends and experts could form part of the access options for learners in a PLE that they would not likely be finding in a self-directed fashion
      • 2. That brings me to the challenges of an open online networked environment for learning. Not all adult learners are able to critically assess what they find online and might prefer to receive guidance from knowledgeable others
      • educators have highlighted that there is a real need for critical literacies while learning informally on networks
      • people might not necessarily have the critical literacies required to learn and search independently
      • Learning in my view is not synonymous with accessing information, and requires a level of reflection, analysis, perhaps also of problem solving, creativity and interaction with people to be able to get the best out of the structures and sub-structures of the Internet
      • the majority of people in the northern hemisphere should now have access to technology (so happy to see Rita qualify the statement with “…in the northern hemisphere…”)

      • The people least likely to use the Internet are also the least likely to participate in adult education
      • And I haven’t even spoken about the people on the southern half of the globe, where the access and participation rate to technology and learning is even lower and the group of vulnerable people greater. Should we just leave these people behind?
      • The components that were formulated in Stephen Downes’ vision for a PLE at the start of the PLE project of the National Research Council of Canada are the following: 1. A personal profiler that would collect and store personal information. 2. An information and resource aggregator to collect information and resources. 3. Editors and publishers enabling people to produce and publish artifacts to aid the learning and interest of others. 4. Helper applications that would provide the pedagogical backbone of the PLE and make connections with other internet services to help the learner make sense of information, applications and resources. 5. Services of the learners choice. 6. Recommenders of information and resources.
      • Having been born into a world where personal computers were not a revolution, but merely existed alongside air conditioning, microwaves and other appliances, there has been (a perhaps misguided) perception that the young are more digitally in-tune with the ways of the Web than others
      • Apparently, the students favor search engine rankings above all other factors. The only thing that matters is that something is the top search result, not that it’s legit.
      • many students trusted in rankings above all else
      • researchers found that even in this supposedly savvy minority, none actually followed through to verify the identification or qualifications of the site’s authors
      • students are not always turning to the most relevant clues to determine the credibility of online content
      • Several strands of research demonstrate that displaying a personal interest in students is not only effective as a way to encourage participation and engagement, but necessary for real learning negative emotions such as fear and shame, all too common in the college classroom, retard learning, due to “choking,” the shutting down of higher-order thinking, and the activation of more primitive areas of the brain associated with the fight-or-flight syndrome

        undergraduate students repeatedly mention the importance of one-to-one interaction with instructors. Displaying a personal interest in students is the first step toward demonstrating that community exists within the classroom and across the campus

      • Be available to students in ways that you judge are not too invasive of your personal boundaries

        Encourage and respond to email

        Solicit and respond to student feedback

      • Mid-semester evaluations that you create and use to fine-tune instruction midstream also convey to students that you care what they think and about their learning

        During discussions and other interactions with students, really listen to them, striving to hear what students are really saying; not what we want to hear and/or assume students are saying

      • making connections between academic material and students’ personal experience also conveys an interest in students and their learning.

    Thoughts on social networking with 3rd year physio students

    Earlier this week I ran a workshop with our 3rd year physio students, as part of my SAFRI project where I’m looking at how participation in a social network can impact reflective learning practices in a community. Unlike the other workshops I’ve run, I’m going to be running this assignment, which will see the students posting 2 reflective pieces based on ethical dilemmas they’ve experienced while on their clinical placements. I was struck by a few thoughts as I was going over some of the activity I observed both during and after the workshop.

    This group is by far the most technologically sophisticated group I’ve run the workshop to date. As we were setting up their profile pages, some of the students were logging into their Facebook accounts to pull in those photos to add to our social network. Most of what I was explaining wasn’t new, and even for those who have no experience with any other social networks, they caught on pretty quickly.

    I learned that at least one of them enjoys photography, and not only enjoys it but shares his fantastic pictures on Tumblr. I would probably never have learned that about him if it wasn’t for this little experiment of mine. I think that that’s one of the enormous benefits of social networks…that we might actually engage with students in ways that would never come up in class. I mean, how many times do we ask students what their hobbies are? And even if we do, and they choose to mention it, will it ever match up to being able to see it? After exploring some of the photos from this student, I came across one of his short posts, which is one of the most inspiring things I’ve read in a while.

    It was quite exciting for me not to have to listen to any moaning when I introduced this assignment. I also haven’t read anything negative about either the assignment or the network, which is refreshing. I did have one student report that the “workshop sucked”, although he hasn’t yet responded to my request for any suggestions for improvement. We still have issues with some of them not having computer or internet access at home, but I think that being on campus for at least a short while during the week is enough time to participate.

    I have one more workshop to do with the first year students, which I’m hoping to finish sometime next week. Then it’s just a case of waiting for the assignments to finish running, survey the students to determine their experiences using the network, and finally to analyse their activity to see if there was any reflection / community building going on. I’m going to actively facilitate this group, as opposed to the relatively passive stance that other lecturers took when their assignments were running. I’m interested in seeing if this group has a better experience with active facilitation, as opposed to just being left to their own devices.

    The role of feedback in medical education

    This reflection on the role of feedback in education is based on a mailing list discussion as part of the SAFRI programme, as well as on a few of the assigned readings. I thank the organisers of the session, as well as all the participants in the conversation.

    Guidelines for effective feedback

    The assigned readings seem to focus on providing readers with a list of guidelines for providing effective feedback and while this list is not exhaustive, it serves as a starting point. Feedback is better when:
    • It is promptly given
    • It is specific to the task being assessed, and to the objectives that were set (of course, this assumes that the student has set objectives for the task)
    • It is performance-based i.e. the feedback is along the lines of what you did, as opposed to who you are. One participant made the point that while it is performance-based, it is done to improve performance, and not to evaluate it
    • It does not focus on too many things
    • It helps the student plan for future learning
    • Feedback should seek to encourage self-assessment, self-reflection and self-awareness
    • Should / Could be better received if the supervisor / clinician allows the student to comment first e.g. What did they think went well? What did they think could be improved? (one participant said that “…a lot of feedback that I have to give to students is actually on written assignments [which]…means that we cannot start with the student’s agenda. There is no interactive discussion, no possibility to listen, respond to non-verbal cues, observation, etc.”
    • Positive feedback should be given first (builds self-esteem and encourages better performance)
    • This positive feedback should not be followed with a qualifier e.g. “You did well, but…”
    • “Listen and ask, don’t tell and provide solutions”
    I’m glad someone pointed out that this (long) list is wonderful in ideal situations but is impractical in many real-world situation, which is where we find ourselves most often e.g. large student:teacher ratios, overloaded faculty and limited time to spend with students. On further reflection, it seems clear that this issue is not specific to feedback, and affects almost everything we want to do as teachers. The problem with teaching is that the way we want to do it (i.e. small groups with focused attention) doesn’t scale very well and we need to come up with a fundamentally different approach to teaching. My own view is that the internet and various associated technologies can enhance communication in ways that do scale, and that therein lies part of the solution.

    Complexity in feedback

    My own initial thought on a list of guidelines was that it was a wonderful “how to” for providing effective feedback to students. However, as I progressed through the conversation, I began to have my doubts, starting with this one. I worry that having a list of guidelines may deceive us into thinking that if we follow the list then we’ve given good feedback. This is like a student thinking that following a list of questions is a good way to conduct an assessment. Giving feedback seems to be a dynamic process, affected by context (e.g. social / cultural background, type of placement / task) and an understanding of the person/ality receiving it. Someone suggested that the complex process of giving / receiving feedback was also about the identity and character of the receiver and that “…in order to protect the integrity of their beliefs and knowledge, [they] will reject corrective feedback and find ways to devalue it”. Some studies have identified the importance of eliciting thoughts and feelings before giving feedback, which might go some way to alleviating this.
    One of the participants insightfully related this back to the MBTI session in March, where it was clear that “knowledge of personalities is useful when giving and receiving feedback. What we know about ourselves and others is important feedback management”. In relation to this, another participant raised the point that “…the issues of culture, gender, religion, belief, age are very important in feedback.  Also, feedback for average students is different than feedback for failing students [as well as for] students who think they’re doing well [but] are actually failing”. I think it’s important to note that feedback is dynamic, contextual and complex.

    Inappropriate feedback

    I found a common theme in the conversation that went along the lines of “feedback drives learning”. This may be a matter of semantics but I’d like to challenge the idea that it does drive learning and suggest that it can drive learning. This may seem pedantic but I think it’s important, because when we say (or imply) that it does, we’re operating under the assumption that all feedback is equal, which it clearly isn’t. This was pointed out by several participants, who suggested that feedback can be inappropriate “…because of how, when or where it is presented”. Some teachers seem to be guilty of using feedback to highlight their own skills and knowledge, while at the same time making it clear that the student lacks these things (or in one horrifying example, actively humiliating them).
    When using my own experiences to make a point, I often include examples of my mistakes. I think that as role models, we need to model our failures (and to elaborate on how we moved past them) as well as our successes. Students seem to have an idea that we’re infallible, which unfortunately makes them believe they must be too. If we can highlight that we’re also subject to errors of judgement and prone to forgetfulness (a big one for me), we show them that we’re human and go a long way to establishing trust.

    Feedback as a skill

    There was a suggestion that giving “feedback is a skill that has to be learnt” and that we should emphasise its importance. This was taken further with the idea that receiving feedback is also a skill that needs to be learnt (e.g. listening, reflecting, analysing), and that we need to spend a lot more time preparing students to receive feedback effectively and with the right attitude / mindset. One participant spoke of students who receive feedback defensively, negating it whether it was appropriate or not. I liked the idea raised that feedback should not only emphasise knowledge, but also more generic skills like effective communication, conflict resolution, etc.

    Feedback in teaching and learning

    It was pointed out that feedback is not only about a student-teacher interaction, it can also be between peers or colleagues. In fact, feedback is “…for helping all who are interested in self development and actualization of goals, not only students”. This suggests to me that feedback between peers could be an important component of peer teaching, an area of that I’m increasingly interested in.
    Feedback should also be given to students who are performing well. This will help to dispel the notion that feedback = criticism. It was pointed out that as teachers, we often have a tendency to focus on the student’s weakness (I know that I’m guilty of this), possibly as a remnant of our own experiences of being students, when this is how we received it. One of the dangers of focusing on the negative only, is inducing a lack of confidence on the students part, where they become incapable of identifying their strengths. Thus, feedback should be used to highlight strengths as well as weaknesses, in order to promote learning.

    Feedback and evaluation

    Before beginning, see the third point in the guidelines. All too often (as was pointed out by some participants), feedback = marks, and there is no action required after receiving the mark (or if there is, the response is along the lines of “What must I do to get a higher mark”). I wonder if we’re not the problem. We make the assumption (and model behavior showing) that feedback and marks are related, whereas they don’t need to be. Marks are quantitative, while feedback is qualitative. Marks are summative, feedback is formative. Apples are apples and oranges are oranges. When one person is evaluating another, there’s no real objectivity, and so quantitative measures of competence don’t seem to me to be a good fit.
    We should distinguish between formative and summative assessment, and their relative relationships to feedback. In formative assessment, feedback is essential as its nature is to facilitate learning. In summative assessment, feedback is irrelevant because the nature of the examination is to evaluate, which we’ve seen is not the role of feedback.
    I think we need to get away from this idea that feedback and marks are necessarily related. Of course they can be, but it doesn’t mean they must be. We have to disconnect feedback, which is about learning, and marking, which is about evaluation (and not a very good form of evaluation at that). If students are “marks driven” it’s because we’ve put marks at the centre of our curricula. How do we de-emphasise marks…well, by not marking (it’s radical, I know).

    Feedback and reflection

    In order for feedback to be effective and of any value, we must first identify the relationship between the task, the feedback, reflection on the task and feedback, and finally, acting on the feedback. Without first making sure that the receiver understands this, the feedback is of no value. We know that reflection drives deep learning, understanding and professional development, yet we leave little space in the curriculum for structured reflection (and forget about teaching students how to reflect). It was great to read the comment, “we do not learn from experience, but rather from reflecting on experience, and feedback must facilitate this reflection for the student”. I would argue that unless the feedback results in a behavioral change, it is ineffective. Of course, if the student cannot focus on anything but the mark, we clearly haven’t established for them the relationship between the task, the feedback, the reflection and the action.

    “No feedback” as feedback?

    There was a question of whether “no feedback could also be feedback”, and I agree with one response which stated that it was “…the most negative and most useless form of ‘feedback’ in that it borders on pure and simple indifference”, as well as being “regressive and inhibiting”. I’m reminded of a line from “A man for all seasons]]”, in which Thomas More states that …”the maxim of the law is ‘Silence gives consent'”. When I was a student and was not explicitly told to improve (and to do this), then it meant there was nothing to improve, which I found disturbing, knowing what kind of student I was. I worry that if we give no feedback, we risk the student believing that their performance is exemplary (which it may very well be, but then tell them that), or worse, that they don’t know what to believe, leading to anxiety and confusion.

    Feedback as a form of academic literacy

    I’ve also been thinking about feedback as a form of literacy, which was touched on by one participant, who suggested that “…conversation is a form of feedback, a sort of negotiation of understanding in which mutual feedback becomes recursive leading to shared understanding.  In this way, feedback is not one person who ‘knows’ helping another person who doesn’t ‘know’, rather it is mutual. By asking myself questions before and during the feedback, I am learning at the same time the other is learning”. I would take this in a more general direction and suggest that feedback is useless unless the student is at least familiar with the culture of the tribe, which includes the language and conventions we use.
    We can give as much feedback as we like, but if we’re speaking a language the student doesn’t understand (I don’t mean English, etc.), we’re wasting everyone’s time. And in case you think that by final year, our students understand our “tribe”, think about this simple example: The first year student is starting out in the culture of higher education, the second year student is starting out in the culture of physiotherapy, the third year student is starting out in the culture clinical practice, and the final year student is starting out in the culture of being a physiotherapist. We need different languages and approaches for each of these different cultures / literacies / “tribes”.

    Final thoughts

    • For most of the discussion, feedback was treated as a “thing”, rather than a process or interaction. My own view is that feedback is neither “given” nor “received”, but is a process that people participate in
    • How many of us ask our students for feedback on our feedback?
    • How many of use ask our students for feedback on our teaching? One participant had this to say “Should each of us offer the students who receive our teaching the opportunity to give feedback on our teaching as part of their learning? This may be a little threatening, but on the occasions that I have done so in the past it has mostly been encouraging and affirming. Occasionally uncomfortable.”
    • If we do ask for it, how many of us reflect on it and make an associated change in our teaching practice?

    Twitter Weekly Updates for 2010-03-29