The use of feedback and feed-forward action plans on the development of clinical skills in undergraduate medical students.
Abraham, Reina Mary.
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Background: Deliberate practice is a concentrated learning strategy aimed at achieving a defined goal and feedback enables skills and behaviours to be corrected or reinforced for improved patient care. Clinical skills are initially taught during the pre-clinical years in a clinical skills laboratory using simulated patients and manikins before applying them on real patients. There is a need to increase medical students’ engagement, orientation, acceptance and assimilation of feedback to enhance their clinical competence. To move feedback forward and to encourage a change from a unidirectional teacher-learner dialogue to a co-constructed dialogue, feedback strategies or ‘feed-forward action plan interventions’ need further investigation. Aim: To explore the medical students’ receptivity to feedback, their engagement with feedback interventions and the role of deliberate practice in tutor and peer clinical skills logbook formative assessment feedback. Methods: This mixed methods study comprised of both quantitative and qualitative aspects. Five semi-structured focus groups were conducted with twenty-five purposively selected third year medical students. In the first study, data was thematically analysed through a psychological framework, underpinned by four psychological processes: Awareness, Cognizance, Agency and Volition, to understand learner behaviour to feedback reception, interpretation and uptake. In the second study, high and low academic performing students’ experiences of self and peer feedback was explored. In the quantitative part of the study we adapted and developed a feedback scoring system based on the deliberate practice framework to assess the quality of the feed forward strategy implemented in the 2nd and 3rd year medical students tutor and peer logbooks to identify deliberate practice components i.e. task, performance gap and action plan. The sample consisted of 1025 feedback responses. Results: This study found that awareness, understanding, agency and volition revealed facilitators and barriers to feedback receptivity. Feedback aligning with the personal goals of the learner, the reliability of the teacher in delivering feedback and establishing relationships strengthened reception. The depth and timing of feedback utilization varied among students as their self-regulatory focus on the feedback process dominated their active use of feedback. Students with lower performance believed they lacked adequate skills to engage with self and peer feedback interventions. Higher-level students reported that receiving peer input helped them take responsibility for tracking and assessing their learning, suggesting that students require numerous self-evaluation opportunities to improve their judgment over time. Teacher feedback on interventions testing clinical cognition had a positive impact on feedback engagement and self-regulating learning. Analysis of the 2nd and 3rd year written feedback revealed all three deliberate practice components with a higher peer than tutor frequency in both classes respectively. Decreased student achievement was associated with increase in tutor gap xii and action feedback scores and vice versa in peer scores. The overall quality of feedback provided by tutors and peers was moderate and less specific (average score < or =2). Conclusion: Using the deliberate practice framework improved the feed-forward quality of feedback as comments contained elements facilitating deliberate practice. Providing constructive feed-forward feedback linked to tasks learning objectives and assessment outcomes has the potential to promote self-regulation by stimulating self-awareness and self-directed monitoring through reflection-in-action. The less competent learners received and used feedback differently and the above effects were either immediate or undeveloped. To motivate immediate feedback engagement due to their self-regulatory focus of postponing feedback use closer to exams, this study recommends the novelty of integrating the logbook sessions with a feedback design that makes learners actors in the feedback process after receiving feedback. Newer feedback initiatives that target a feedback intervention for learners to scaffold feedback by reflecting and formulating self-generated performance improvement goals based on what they did well and areas that need improvement would serve as a source of coaching to facilitate feedback interpretation and utilisation to feed forward. Goal setting supports learners’ active engagement with feedback by stimulating them to read and understand the feedback, identify areas that require development, develop learning goals and then convert these goals into action by adjusting their behaviour. Equipping learners to engage with peer feedback processes through the feed forward intervention enables development of shared responsibility and self-directed learners with greater agency over assessment and feedback process. Responsibility sharing has the potential to ensure sustainability of the educator’s effective feedback practices reducing the emotional burden on both students and educators. This study emphasises the importance of a clinical skills feedback culture as a faculty development programme to strategically direct student learning by reinforcing desirable behaviour change towards professional identity and professionalism. Further, a novel approach based on psychological processes to understand the barriers and facilitators of feedback receptivity is proposed. Using a theoretical framework based on deliberate practice and feedback intervention theories, this study expands our understanding of factors influencing the situational and learners’ self-regulatory use of feedback. In addition, a conceptual framework and a feedback-scoring tool are proposed to pave the way for moving feedback forward and to highlight the importance of feedback-feed-forward action plans. Key words: Clinical Logbook; Feedback; Evaluation; Deliberate practice; Feed-forward; Feedback literacy; Feedback culture; Clinical skills, Formative Assessment.