The educational benefits of giving effective feedback in the clinical setting.

Feedback has a special role in medical education – For clinical learners, it is a key step in the acquisition of clinical skills, it leads to enhanced learning and is crucial in their development into competent clinicians.  It is critical, in the context of patient care, as if feedback is not provided, mistakes go un-corrected, good performance is not reinforced and clinical competence may not be achieved at all.

Why do students and trainees continually complain about lack of feedback or poor feedback?

…..and why then is it done so poorly? 

A number of situations contribute to the ‘lack of’ or ‘poor’ feedback

  •  misconception between the terms feedback and evaluation/assessment.
  • a focus on the trainees themselves rather than on the trainees observable behaviours
  • lack of observation – clinical skills frequently unobserved, and
  • when they are observed… the information doesnt actually get back to the student/trainee or is handled inappropriately ie poorly communicated

The aim of this post is to provide clinical teachers with

  • a clear understanding of the feedback process
  • analyse some of the barriers that interfere with feedback
  • highlight the consequences for clinical training if feedback is ignored or handled poorly
  • provide practical guidelines/ examples of giving effective feedback

The difference between feedback and assessment
When we give feedback, we are observing performance (of an activity/skill) in order to provide information that will guide future performance of that activity or is formative and specific and promotes future learning.  It is not a judgement on performance.  Assessment on the other hand is summative, it comes after the fact and presents a judgement on how well or poorly criteria is achieved,  often in relation to a specific standard.

The feedback process

  1. Preparation

Articulate learning goals
We firstly need to understand the learning goals of the student or trainee, the conversation needs to occur up-front and explain why it is important, and what we hope to both get out of it. i.e. Learners identify what they would like to get out of their rotation (or learning activity) These can be articulated as specific, measurable…..  Once the goals are set, it is then important to close the loop and provide feedback on how the learner achieved those goals.

To ensure the correct information is given, the supervisor needs  to ‘observe’ the learner… actually see first hand ‘how’ they perform a clinical task, skill or manage a patient encounter. Therefore feedback should be based on first-hand data – if you weren’t there you didnt see the patient, don’t judge what was going on.

2. The feedback meeting

Two way conversation or exchange (being open)
Feedback involves a mutual two way discussion where both supervisor and learner contribute their perspectives of the activity/performance. Invite dialogue and reflection. The learner reflecting and the supervisor questioning/guiding/telling.  Feedback is effective when the learner is offered insight into what he or she actually did as well as the consequences of those actions.   If is a valuable component to improve learning as it highlights the dissonance between the intended result and the actual result…which provides the impetus for ‘change’

Questioning and telling
The key strategies utilised in this discussion are good questioning techniques and then being able to ‘tell’ the learner, providing specific examples on what they did well, plus clear and specific ways on how they can improve.

The questioning techniques also help students reflect and assess their performance and at the same time, gain more insight into what they did well and what areas need improvement.

It is of no use to a learner, if the feedback is vague -“you are doing a great job” doesnt provide useful feedback at all.  Also avoid subjective statements “that was stupid, wasnt it? helps no-one. Having observed the performance, the supervisor is able to provide explicit details on the learners strengths and what areas need improvement, with suggestions on how they can improve.

3. Action

Being specific

Supervisors need to be honest with the learner about their performance and how they see things.  Providing the learner with constructive ways, and specific examples of what they can do in the workplace or next time they manage a patient that will actually  ‘improve’ their approach.  However dont overload the learner – stick to the behaviours they can change – and plan in advance on one aspect they can focus on to develop.  Working through cases can help the trainee pull out learning points to other context or patient situations.


Questioning:  what do you think went well?
Telling: You interacted with that patient well

Questioning: What areas would you like to improve
Telling: You should try this next time

Questioning: Where do you see yourself now in relation to your learning goal
Telling: You are developing excellent communication skills

Say Thank You

Self reflection


The narrative in learning design

The narrative, conversational storytelling is a common component in creating engaging learning through all teaching and learning modalities #presentationskills, podcasts, video, game based learning, simulation, case based scenarios

The learning experience has more meaning and impact by including the narrative – the STORY

The story adds context, adds connection for the learner, adds emotional impact.

Definition of a story:
“A character-based narration of a character’s struggles to overcome obstacles and reach an important goal” (Kendall Haven, Story Proof).

What ever medium the story has structure: a beginning, middle and end. Structure helps build your narrative:

1. Commence with a strong opening.

Whether you are delivering a presentation, designing an online learning activity or creating a podcast/video game, you literally have 90 seconds or so to make your learner/audience  feel something powerful, the ‘hook’ to get their attention and keep them interested. (Don’t waste time listing the 27 objectives).

2. Interesting middle – the middle of your story may cover the obstacles, the alternatives, the path you followed and the insights along the way.

A good story is a mixture of logic, data, emotion and inspiration (Andrew Stanton)

3. Ending
Powerful finish – if your audience only remembers one thing …what will it be?

Virtual chats transcending the physical, time and space…


Twitter is the closest thing we have 2virtual speech. The text “bites” similar in length 2reg convo. Gr8 training ground 4all communication.  Bernadette Keefe MD @nxtstop1

  • Crucial conversations for educators and students

After the #HMIchat  in January 2017, memories flooded back of a virtual classroom activity that occurred during a synchronous chat room event many years ago (2004).  The chat room was set up inside our learning management system – so participation consisted of members of our course group – however similar to the HMIchat it was a global community – we had students (educators) in our course from all parts of the world.

The course was “Teaching online strategies and tactics”, (part of a Masters in Educational technology at USQ).  It explored the principles of online pedagogy, and examined different ways to engage and teach students online. The course, itself was totally online and we were able to immerse ourselves in the different communication options available within our LMS – not quite as diverse as what we have available today with social media, but enough to experiment and explore.

The particular session in 2004 was so close to ‘real’ conversation or a brain storming activity that it left participants feeling speechless – comments included:

“What we experienced was like astral traveling into each other’s consciousness and connecting at such a fundamental level that it caused a euphoria of sort”

…the soul can transcend the physical

…a sense of sharing…not demonstrating…or observing but really sharing…

…we embarked on an adventure and admitted vulnerability by surrendering to the moment – we were truly ‘in the moment’

we were perceived as real people, even transcending this to a plane that I have only experienced in a period of intense meditation, where bodies, personalities, souls merge so that you are no longer aware of how or why this is occurring but you feel “at one” with the experience. Even the medium becomes irrelevant.

..we were in fact engaging in  high level pedagogy and reached the ‘max’ or the ‘peak’ of interaction.

So what are the characteristics that made the chat successful?

The human – ness of the virtual conversation can be defined as ‘social presence’ which generates a feeling of safety, mutual respect, connectedness  and willingness to share.

In our group chat there was mutual respect, and a knowing among participants that it was safe to contribute, safe to have your say, safe to have an opinion, safe to disagree.

..A sense of sharing and a desire to share – not demonstrating or observing but really sharing. Leaving your ego at the door (a disassociation from roles) and being prepared for anything – the parameters are articulated but the possibilities are endless.

A pre-determined agenda is important, it forms the basis for discussion, and allows participants to prepare for the activity. The post chat discussion is also worthwhile, to allow the participants to critically reflect on the key points, outcomes, issues and further meaning making.

The role of the moderator is also critical, they need subtly guide the conversation, allowing different pathways to be explored and if required to bring the group back on topic.   However in such a fast paced meeting of minds,  the moderator has to be quite skilled to keep track of the different threads, which can at times seem out of sync.

Today’s tweet chats offer the same virtual space for collaborative learning, where educators actively exchange ideas, explore perspectives, debate and problem solve in the context of a  ‘community of practice’.

As mentioned the tweet chat can be used as reflective practice, participants critically reflect their practice, on their contributions and those of others.

This type of conversational discourse is beneficial  for developing students digital literacy skills,  and as Bernadette Keefe tweeted, what  a great training ground for communication.  Tweet chats engender the idea of active learning – students shifting from passive to active engagement. Being able to co-construct knowledge through collective learning, sharing of perspectives and meaning making.

As educators we can encourage students to participate, share and collaborate in virtual spaces to develop and enhance their communication skills; to reflect on their learning; to explore perspectives and gain new understandings.  This highly interactive learning activity can transform the student learning experience.

Acknowledgement: Dr Shirley Reushle, Lecturer Teaching Online Strategies and Tactics, Faculty of Education, University of Southern Queensland.2004

Presentations and learning design



look and feel of course
eLearning & mobile learning presentation – NSW Prevocational Medical Education Forum – 2012

Online Design

Through my work in online learning design I have developed a set of design principles that underpin the way in which content should be presented to firstly attract the learners attention and keep them engaged through the learning experience.

Content: simplistic in form, but visually rich in representation of ideas. With the inclusion of authentic stories and relevant context online content can be dynamic, interactive and thought provoking.

Key considerations in developing online content:
Visual design
1. The look and feel: colour, fonts, consistency, alignment
2. The physical placement of elements on the screen in a way that doesn’t overload the mind. That allows the brain to easily process the information (cognitive load theory)
3. Media – intentional selection of images, video, audio, graphs that add richness to the learning experience.
Active learning design
1. What is the learner going to do with the content – what activities can be included to move the learner from a static/passive observer and consumer of information to active involvement and engagement.
2. Structure and sequencing of activities – the ‘flow’
3. The story – relevant to the learner, authentic conversational.



2. Conference presentations
How many conference presentations have you been to where you have either dozed off, or wished you had selected more wisely, especially when you see from the conference tweets, that there is a more dynamic presentation happening in the session next door.

I also realised that there is a growing unrest with the current state of presentation delivery. Blogging sites with a key focus on presentation skills are emerging to offer an alternative and to help educators with their presentation design and delivery skills.(see list below)

Its through these sites and personally witnessing awesome presenters that I have been able to collect ideas, integrate with my own thoughts,  and create a resource that represents these guiding principles and hopefully illustrates them at the same time.

See Powerful Presentations



Plus visit the sites :

P Cubed Presentations

Vic Brazil
Present better with tech

Natalie Lafferty:
Presentations and learning

Garr Reynolds
Zen philosophy of design

Talk like TED 


Designing a blended learning program to improve student learning outcomes and their confident transition to practice

Traditional medical curriculum focuses on content and the acquisition of clinical knowledge, technical skills and successful performance in the examination setting (low level memorisable knowledge). However this does not formally translate in developing the attributes and skills required to perform in a demanding work environment that is potentially in a state of flux. There is limited formal training for students to develop the non-technical skills to function with ambiguity and complexity, and to develop the process attributes that involve being able to work with others, think creatively, self-regulate and solve complex problems.

Much has been made of producing ‘work ready graduates’ and many medical schools and universities are reforming curriculum to provide enhanced learning however despite these reforms medical students are still experiencing anxiety and consider themselves not confident in their transition from university to the work environment. This transition to practice challenge is not unique to medicine, also occurring in other sectors.

Since 2014, the clinical teaching team at Univerity of Queensland Rural Clinical School (RCS) in Toowoomba have been developing an educational program to prepare students for the workplace. This program aligns with the RCS’s ‘Technology Enhanced Learning Strategy’ which aims to improve the delivery of learning and assessment through the creation of blended learning solutions that can be accessed in geographically distributed/dispersed learning environments.

The program is based on blended learning pedagogy that generates active learning and student engagement. It features a combination of online case based scenarios, face to face role play activities, reflective small group discussions and digital assessment.

The implementation of active learning strategies throughout all components of the blended program ensures that students are continually practising what they would do in a real world context, as well as critically analysing and reflecting on their learning and how this translates to the work environment.

The most significant outcome of this program will be its effect on the lives of the doctors who can begin their independent professional careers with the skills and confidence they need to meet the non-medical challenges of internship. It is expected that the improved workplace skills will lead to positive workplace experience and ultimately have a positive impact on their care of patients.

Supporting Faculty

Medical Schools should aim to provide support for clinicians in the planning, examiner and resource developer roles and work with them to ensure that they are involved, but offer support to reduce the administrative burden of these areas.  This will then allow more time for the teaching/facilitator/mentor roles that are so important to student learning.

Currently I work with the academics, clinical teachers at our hospital, creating learning resources, student guides and electronic assessments to enhance and support the teaching program and the student learning experience.  My involvement in this area will continue to expand with the redesign of learning and assessment in our teaching facility.  More emphasis is being placed on effective eLearning programs, utilising flipped learning approaches along with mobile delivery of both learning resources and assessments.

My involvement in curriculum planning and participation in examinations will grow as we move forward with the implementation of digital assessments and digital program evaluations. My role in the development of electronic work place based assessments and other student examinations (long case examinations, MiniCEX) will have a positive impact for students, examiners and program administrators.  Improving efficiencies and reliability for our student assessment processes.

My commitment to support faculty in their professional development is important.  The faculty ‘teach the teacher’ programs I initiated over a decade ago have changed with access to technologies that more efficient delivery options.  Initially I introduced as a series of face to face workshops but are now delivered through a blended learning program.  eLearning modules support the practical workshops. My future involvement will focus on curating the teaching resources, accessing FOAMed and using social media to expand professional learning networks of our teaching staff.

Cognitive load theory: Learning design principles and strategies

Instructional strategies, learning and assessment design based on cognitive principles

Theory informed instruction:

Components of learning design: visual/interaction/multimedia

  • Learning design to reduce cognitive load
    • Reduce extraneous load
    • Optimise intrinsic load
  • Transfer of information from working memory to long-term memory
  • Intrinsic motivation to promote self-regulated learning

Blended learning and assessment delivery strategy

  1. eLearning –preparation and pre-class readiness assurance
  • Microlearning – bite sized chunks – sequenced / pace / modelling
  • Visual and multi-media design – Potential ways of reducing extraneous cognitive load (through avoiding/minimizing modality effects).
  • Worked examples
    • Authentic tasks
    • Real world context
    • Use of analogies – linking new ideas to what students already know
    • Tasks that require students to provide explanation (the how and why) focus on the meaning
    • Use of stories/ mnemomics for hard to remember content
    • Carefully paced explanation
    • Feedback/reflection – to facilitate self-regulated learning
    • Additional Practice examples
    • Assessment – self tests to practice – to assist students to monitor their own progress and thinking
  1. In-class activities: Interactive workshop
  • MCQs – quizzes to ascertain student knowledge level and to practice
  • Team based collaborative
  • Case based scenarios
  • Worked examples – step by step demonstration – with guidance and scaffolding that is gradually removed with subsequent case scenarios – giving students to move to independent problem solving
  • Using multiple modalities in presentation of content – graphic with verbal explanation
  • Deliberate practice – providing different problems/contexts with similar underlying structure for students to draw upon and translate to the different presenting problem
  1. Workplace learning
  • Applying learning to clinical setting
  • Micro-learning / mobile delivery/ clinical guidelines at point of need/at point of care
  • Feedback specific and clear, focused on task and improvement