Burgess et al.

BMC Medical Education 2020, 20(Suppl 2):460

https://doi.org/10.1186/s12909-020-02280-5

REVIEW Open Access

Feedback in the clinical setting

Annette Burgess1,2*, Christie van Diggele2,3, Chris Roberts1,2 and Craig Mellis4

Abstract
Provision of feedback forms an integral part of the learning process. Receipt of feedback enriches the learning
experience, and helps to narrow the gap between actual and desired performance. Effective feedback helps to
reinforce good practice, motivating the learner towards the desired outcome. However, a common complaint from
learners is that the receipt of feedback is infrequent and inadequate. This paper briefly explores the role of feedback
within the learning process, the barriers to the feedback process, and practical guidelines for facilitating feedback.
Keywords: Feedback, Peer teaching, Clinical teaching, Student peer-to-peer feedback

Background educational progress. However, health professional edu-

Within health professional education, feedback has been cators, students and peers can find it difficult to learn
described as “Specific information about the comparison from one and other through feedback practices [3].
between a trainee’s observed performance and a stand- Feedback practices are often unsustainable, and de-
ard, given with the intent to improve the trainee’s motivating for students [3, 4]. The ability to assess and
performance” [1]. Feedback is one of the most important provide feedback is a learnt skill, requiring an appropriate
forms of interactions between the ‘teacher’ and the level of training.
‘learner’. However, it has been widely reported that This paper briefly explores the role of feedback within
medical and other health professional students are rarely the learning process, barriers to the feedback process,
directly observed and given feedback during their clinical and practical guidelines for facilitating feedback.
placements [2]. Accordingly, there has been increased
interest in the facilitation of feedback [2]. Provision of
Purpose of feedback
feedback forms an integral part of the learning process
Feedback acts as a continuing part of the instructional
(Fig. 1) [2], helping to narrow the gap between actual
process that supports and enhances learning [5]. It is
and desired performance. The feedback process engages
part of an ongoing unit of instruction and assessment,
the learner with information about the quality of their
rather than a separate educational entity [6]. A core
performance, and leads to improvements in learning
component of formative assessment [7], feedback promotes
strategies. Feedback supports learners’ effective decision
learning in three ways [5]:
making, and helps to improve learning outcomes. It
serves as a powerful tool to provide the learner with
 Informs the student of their progress
judgements on their performance, assisting in their
 Informs the student regarding observed learning
needs for improvement
* Correspondence: Annette.burgess@sydney.edu.au  Motivates the student to engage in appropriate
1
The University of Sydney, Faculty of Medicine and Health, Sydney Medical learning activities
School - Education Office, The University of Sydney, Edward Ford Building
A27, Sydney, NSW 2006, Australia
2
The University of Sydney, Faculty of Medicine and Health, Sydney Health Creating a supportive environment for feedback
Professional Education Research Network, The University of Sydney, Sydney,
Australia Requirements for sustainable and meaningful feedback
Full list of author information is available at the end of the article shifts the focus from the provision of feedback to the
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which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
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Burgess et al. BMC Medical Education 2020, 20(Suppl 2):460 Page 2 of 5

learner. The provision of such feedback requires an

understanding of the process, and skill. Although
there may be a desire to avoid upsetting a learner,
this can result in “vanishing feedback” [8], where
meaningful feedback is avoided.
 Lack of external feedback. Without external
feedback, students may generate their own feedback
- but, self-assessment is often wrong [4]. High per-
formers tend to underestimate their own perform-
ance, and lower performers tend to overestimate [9].

Learner reception of feedback

Similar to giving feedback, receiving feedback is not a
passive, simple act. It entails honest self reflection and
commitment to practice and improvement of clinical
skills. Learners are not always prepared for receiving,
and more importantly, accepting feedback. Additionally,
there may be contextual and relational aspects regarding
the feedback [10]. Clearly, acceptance and effectiveness
of the feedback may be dependent upon the perceived
credibility of the provider [10]. The learner is more
Fig. 1 The learning cycle during clinical placements accepting of the feedback if they perceive the provider to
have a good understanding of the curriculum, and the
design of the learning environment that promotes facili- learning objectives.
tation of feedback [3]. Rather than facilitating individual
acts of information provision and reception, feedback Student peer-to-peer feedback
should be viewed as the promotion of active learning. The practice of providing feedback to peers is perceived
Teachers are responsible for fostering interactions be- by students as beneficial to development of knowledge,
tween students and their peers, and students and staff. skills, and professional attributes [11]. Provision of feed-
Learning environments should be created where stu- back from peers can foster high levels of responsibility
dents see themselves as agents of their own change, fos- in students [11, 12], and some students report metacog-
tering self-regulation and driving their own learning. nitive gains [11–13]. However, unsurprisingly, there are
Fostering high levels of student engagement helps to de- real concerns regarding the honesty and accuracy of peer
velop the identity of students as proactive ‘learners’, who feedback [11–15]. The inability of students to provide
seek feedback and reflect on their own performance. constructive feedback to peers has been attributed to
both inadequate training, and social discomfort [16].
Barriers to the feedback process Obviously, students are very concerned about providing
The process of feedback requires interaction and direc- negative feedback to their peers, the quality of their
tion, and should be viewed as essential to clinical educa- feedback, and the consequences of this negative feedback
tion. In the absence of feedback, the uncertainty of a on their peers’ progession [11, 17]. Fortunately, students
new clinical environment for a learner is intensified. find that using a strucutred method for providing feed-
There may be a number of barriers to the feedback back to peers is useful [10, 11].
process, including:

 Lack of direct observation of tasks. Feedback has the Self-assessment and reflection on performance
greatest impact on students’ behaviour when it is Feedback not only has the purpose of improving a
provided based on direct observation of a specific learners’ performance, it also acts as a tool to cultivative
task [2]. In the busy clinical setting, direct self-assessment and reflection on performance. Evidence
observation is often lacking. suggests that self-assessment is inaccurate; high per-
 The desire to avoid upsetting students with honest formers underestimate themselves, while poor per-
and critical feedback [2]. Feedback can be more formers overestimate [1, 9]. Receiving external feedback,
difficult to provide when the learner’s performance however, gives learners the opportunity to benchmark
is below par, and may be disappointing to the their own self assessment against appropriate criteria.
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):460 Page 3 of 5

Effective feedback Table 2 An activity: giving and receiving feedback

Effective feedback is an essential part of the learning Activity 1
process. Effective and regular feedback reinforces good Find a colleague who you may be able to practice giving feedback
practice, promotes self-reflection, and motivates the with, using Pendleton’s model of feedback. Note that although the
learner to work towards their desired outcome [2]. The model is simple, it is not easy to adhere to the set framework.
style of feedback delivery can influence the outcome on What were the positive aspects of the way feedback was given?
the student. Feedback can inspire the student to reflect What could be improved?
and improve their performance, or it can be negative
and demoralising. We have found that using a structured Structure
method, such as Pendleton’s model (1984), illustrated in The timing of feedback needs to be considered for both
Table 1, is useful for providing feedback [11, 18–20]. parties, allowing adequate time for preparation. It may
This model of feedback offers learners the opportunity be necessary to ensure the feedback is given in a confi-
to evaluate their own practice, and identify ways of im- dential location, with the purpose of the meeting being
proving. It also allows for immediate feedback from the made clear to all. The room setting should also be con-
observer. sidered, so to not intimidate the student. It is important
Table 2 provides an activity that allows practice and that feedback is focused on the attitudes, behaviour and
reflection on the use of Pendleton’s model of feedback. knowledge observed, with the use of descriptive words
to assist in the understanding of the feedback. Mutual
Giving effective feedback trust and respect should be established, with the shared
Direct observation, and clear goals are needed in the goal being working towards improving the learner’s
provision of effective feedback, with good performance performance [9].
being reinfoced, and poor performance being corrected
Table 3 Three key areas of a successful feedback session [2]
[21]. Although provision of constructive feedback detail-
Structure
ing both positive and negative aspects of the learner’s
performance can be time consuming and difficult, not • Schedule the feedback session at convenient time for teacher
and student
giving feedback can have a substantial negative effect. If
not relayed carefully, feedback can result in a deterior- • Make the purpose of meeting clear
ation in performance [4, 21]. If handled poorly, feedback • Seating arrangement in the room should show the teacher
as a ‘participant’ e.g. round table
can also cause defensiveness and embarrassment to the
learner. Feedback must be non-judgemental and descrip- • Feedback should focus on observed knowledge, attitudes and
behaviours
tive in nature [22]. There are a number of key principles
to consider when conducting effective feedback [2]. • The format of the session should include self-assessment, teacher
assessment and joint development of an action plan
Namely, feedback should be:
Format

1. Planned, considering the place, timing and • The aim of the feedback session is to improve student performance
- make this clear
environment
2. Explicit • Session structure should be made clear - student self-assessment,
teacher assessment, joint development of an action plan
3. Descriptive
• Use an appropriate feedback model e.g. Pendleton’s positive
4. Focused on behaviour, not personality critique method
5. Specific
• It is important to both give positive feedback and areas requiring
6. Concise improvement
7. Verified by the recipient
• The assessor should provide examples and strategies for
8. Honest improvement
Content
The success of a feedback session is dependent on
• Teachers and students need time to prepare respective content
three broad areas: structure, format, and content, as for the session
outlined below and summarised in Table 3 [2, 23].
• The learner should assess their own learning objectives for the
clinical placement, including formal objectives and personal
Table 1 Feedback model (data from Pendleton et al., 1984) [18] objectives
1. Ask the learner what went well • The teacher should prepare for the session by making direct
2. Tell the learner what went well observations of the student’s performance, and gaining feedback
from others on the team
3. Ask the learner what could be improved
• The teacher should review notes and only select a few points
4. Tell the learner what could be improved to cover
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):460 Page 4 of 5

Format  Orientate students to methods of feedback

It is essential the feedback provided is accurate and valu-  Promote opportunities for multiple tasks with
able, with both negative and positive points being made formative assessment and feedback
[9]. The aim of the session is to improve the perform-  Develop incremental challenges for tasks
ance of the learner. The steps in the meeting include the  Provide opportunities for students to not only
learner’s self-assessment, the teacher’s assessment, as receive, but practice giving feedback1
well as providing an action plan for future improvement
of performance. The key to Pendleton’s model of feed- Conclusion
back is to encourage self-reflection and have the student Feedback is an essential component of the learning
lead the approach to feedback (see Table 1) [18]. process, and is considered an integral part of the cur-
riculum. Despite the growing body of literature sur-
Content rounding feedback, there is little agreement on the best
Adequate time needs to be provided in order for the approach. No single feedback model will work across all
teacher and learner to prepare for the meeting [9]. For- clinical contexts. Each clinical educator needs to engage
mal learning objectives and personal objectives need to in the process of feedback, and can take the opportunity
be considered when assessing what learning has taken to develop their own best practice. Regular and effective
place. Having the teacher directly observe the student’s feedback helps to reinforce good practice and motivate
performance will provide specific examples of good per- the learner towards the desired outcome. Because skills
formance, and areas for improvement. Only a limited in giving and receiving feedback are rarely taught to
number of specific areas for improvement (say two or health professional students, they are often lacking in
three of the most crucial only) should be addressed in a clinicians. Direct observation and feedback offers a
single feedback session. powerful tool to inform the learner of their progress at a
specific point in time [24, 26]. In order to increase the
The role of curriculum design in promoting feedback efficacy of the educational process, it is important for
The curriculum should be deliberately designed to in- both learners and teachers to understand the purpose
spire students to engage in feedback [3]. Feedback and structure of feedback.
should be viewed as a required element of any curricu-
lum, and central to student learning. Interventions to Take-home message
promote feedback need to ‘permeate’ the curriculum
and the culture of organisations, to ensure learners are • The learning environment should foster feedback.
able to identify appropriate standards to apply to their • Effective feedback has the potential to improve skills and change the
work [3]. Fruitful learning environments should be con- learner’s behaviour.
structed by students to practice and actively build on • Using a structured format to provide feedback (such as Pendleton’s
their ability to make judgements about their own work. model), assists in self-reflection and the provision of clear, constructive
Comparisons of performance should be encouraged advice.
early in the curriculum. This helps students to develop • The curriculum should be deliberately designed to inspire students to
engage in feedback.
an awareness of their current capabilities, and plan for
their own learning needs.
Self regulated learning (SRL) offers a process that em- Abbreviation
SRL: Self regulated learning
powers students to actively engage in and direct their
own learning [24]. The use of SRL helps students to set Acknowledgements
goals, actively engage in learning activities, and monitor Not applicable.
their own progress and actions in achievement of their About this supplement
goals [24, 25]. Feedback can be given to students on This article has been published as part of BMC Medical Education Volume 20
their use of SRL to encourage strategies in learning that Supplement 2, 2020: Peer Teacher Training in health professional education.
The full contents of the supplement are available online at URL.https://
are clear and specific, self-monitored, and reflected upon bmcmedicaleducation.biomedcentral.com/articles/supplements/volume-20-
[25]. The challenge for educators is to systematically supplement-2.
build self-analysis as an expectation within the curricu-
lum. Regular self-analysis helps to build habits that pro- Authors’ contributions
AB, CM and CVD contributed to the drafting, writing, and critical review of
mote comparison between self-analysis and external the manuscript. CR contributed to the critical review of the manuscript. All
analysis [3]. Tips for designing a curriculum that posi- authors read and reviewed the final version of the manuscript. The author(s)
tions feedback as a key attribute include: read and approved the final manuscript.

Funding
 Orientate the students to the purpose of feedback No funding was received.
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):460 Page 5 of 5

Availability of data and materials 22. Chowdhury R, Kalu G. Learning to give feedback in medical education.
Not applicable. Obstet Gynaecol. 2004;6:243–7.
23. Bienstock JL, Katz NT, Cox SM, Hueppchen N, Erickson S. To the point:
Ethics approval and consent to participate medical education reviews – providing feedback. Am J Obstet Gynaecol.
Not applicable. 2007;196(6):508–13.
24. Zimmerman BJ. Becoming a self-regulated learner: an overview. Theory
Pract. 2002;41(2):64–72.
Consent for publication 25. Leggett H, Sanders J, Roberts T. Twelve tips on how to provide self-
Not applicable. regulated learning (SRL) enhanced feedback on clinical performance. Med
Teach. 2017;11:1–5.
Competing interests 26. Huggett N, Jeffries WB. An introduction to medical teaching: Springer
The authors have no competing interests to declare. Netherlands; 2014. https://doi.org/10.1007/978-94-017-9066-6.

Author details Publisher’s Note

1
The University of Sydney, Faculty of Medicine and Health, Sydney Medical Springer Nature remains neutral with regard to jurisdictional claims in
School - Education Office, The University of Sydney, Edward Ford Building published maps and institutional affiliations.
A27, Sydney, NSW 2006, Australia. 2The University of Sydney, Faculty of
Medicine and Health, Sydney Health Professional Education Research
Network, The University of Sydney, Sydney, Australia. 3The University of
Sydney, Faculty of Medicine and Health, The University of Sydney, Sydney,
Australia. 4The University of Sydney, Faculty of Medicine and Health, Sydney
Medical School, Central Clinical School, The University of Sydney, Sydney,
Australia.

Published: 3 December 2020

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