Feedback is a form of communication and is a crucial component of clinical education (Kaprielian & Gradison, 1998; van de Ridder, Stokking, McGaghie, & ten Cate, 2008). Indeed, feedback has been referred to as the cornerstone of effective clinical teaching, and empirical evidence has shown that it can significantly improve clinical performance (Cantillon & Sargeant, 2008; Eggen & Kauchak, 2007). Traditional clinical feedback must be expanded to meet the needs of the learner in the current complex health care environment, which demands interprofessional teamwork. The purpose of this article is to present an expanded approach to feedback that consists of the following five steps that educators can take to provide effective feedback in the clinical setting to teach teamwork and collaboration: (a) create a culture of feedback, (b) use structured communication tools, (c) encourage dialogue, (d) acknowledge the human factor, and (e) embrace a leadership role. This novel approach prepares students to effectively communicate and collaborate by providing and receiving feedback from other health care providers.
Barriers to effective feedback in the clinical setting include unclear expectations and goals, no appropriate time or place for feedback to occur, and the tendency for a one-way flow of information from the educator to the learner (Archer, 2010). To be effective, feedback must be presented in a way that allows the learner not only to comprehend and accept feedback but also to know how to apply feedback in practice (Cantillon & Sargeant, 2008; Ramani & Krackov, 2012).
Traditionally, providing feedback has been the task of the clinical educator (instructor or preceptor) who observes the learner’s (student or orientee) behavior and provides expert direction (Ramani & Krackov, 2012; van de Ridder et al., 2008). However, the current need is for both clinical faculty and students to use feedback-seeking behaviors to understand ways to improve effective teamwork and collaboration (Crommelinck & Anseel, 2013).
Providing clinical instruction has become increasingly difficult for educators due to the current complex health care environment. Barriers to clinical education include diversity of settings, complexity of patient populations, limited clinical sites, and time constraints for teaching. Clinical groups may have as many as 10 students per clinical instructor, and preceptors are often undertrained (Cantillon & Sargeant, 2008; Clapper & Kong, 2012; Salas et al., 2009). The protection of professional standards, the self-esteem of students, and the rights and safety of patients must be priority considerations in any clinical learning experience (Archer, 2010). The Joint Commission recognized that breakdowns in communication were the leading root cause for sentinel events between 1995 and 2006 (World Health Organization, 2007). In response to the Joint Commission’s report, the National Patient Safety Goals were established to improve the effectiveness of communication and promote team training programs (American Society of Registered Nurses, 2008; Berg, Wong, & Vincent, 2010; Salas et al., 2009). The Interprofessional Education Collaborative’s Expert Panel (2011) responded by recommending the continuous development of interprofessional competencies by health professions students as part of their learning. Teamwork and collaboration is one of the six Quality and Safety Education for Nurses core competencies for prelicensure and graduate nurses developed by the QSEN Institute (Barnsteiner, 2011). The provision and acceptance of feedback in the clinical educator–student dyad will help to develop the teamwork and collaboration skills needed in the current complex health care environment.
Teamwork and Collaboration Skills
Step 1: Create a Culture of Feedback
To create a culture of feedback, educators must consciously embed feedback implicitly and explicitly into all clinical activities so that it is viewed as a normal, everyday component of the clinical experience and is conceptualized as a sequential process, instead of as a series of unrelated events (Archer, 2010). This begins with the clinical educator modeling a climate of mutual respect by ensuring that the goals and expectations of the clinical experience are clearly understood and embraced by the learner (Ramani & Krackov, 2012). The learner needs to understand that feedback will be given throughout the clinical day in multiple venues and from a variety of sources. Feedback can be provided in a reciprocal one-to-one method between the educator and the learner, but it can also be provided during facilitated group discussion or dialogue sessions with students, nursing staff, other health care providers, or patients. Effective feedback is a two-way interaction, and the learner is encouraged to provide feedback to the educator as well (Archer, 2010; Ramani & Krackov, 2012; van de Ridder et al., 2008).
Surveys of learners’ preferences indicate that learners want feedback, but, although educators believe they are providing adequate feedback, it is often not what the learners themselves perceive (Cantillon & Sargeant, 2008; Ramani & Krackov, 2012). Many educators find that providing feedback is an uncomfortable responsibility because they find it difficult to separate the task or performance from the individual learner (Cantillon & Sargeant, 2008). The educators may not know how to respond to the emotional reactions that can result when feedback is perceived by the learner as being negative or critical. Most individuals do not take kindly to criticism, even when it is offered as constructive criticism, because criticism in any form often comes across as being evaluative and judgmental, even if it is meant to be helpful. The key to providing feedback is to encourage the development of self-reflection, sometimes used interchangeably with self-assessment and self-efficacy, to help the learner understand certain events and accept feedback, with the aim of self-improvement (Stone & Heen, 2014). It is time for educators to take a cue from the current health care paradigm shift from a culture of error and blame to a culture of safety and encourage learners to review their experiences in a climate of shared learning, instead of shame, guilt, and punishment. This culture of safety creates an environment where it is more likely that good practice will be reinforced and poor practice will be corrected (Bates, n.d.; Cantillon & Sargeant, 2008).
Students assigned to clinical groups are in the ideal position to learn team-building skills. A team is defined as two or more individuals who work toward a common goal and whose behaviors, cognitions, and attitudes combine to create an adaptive and interdependent performance (Weaver et al., 2010). The team becomes the structure for providing feedback and support. A team attribute is that no one particular person has all the answers, but through effective communication and collaboration, team performance can be improved and goals can be met.
The team approach establishes a culture of feedback that encourages continual learning and improvement. For example, a student is given the opportunity to place a nasogastric tube in a patient. After reviewing the procedure and collecting the appropriate equipment, the student attempts to place the tube, but on the first few attempts it curls up in the patient’s mouth. The instructor makes several suggestions, and on the next attempt, the tube goes down the trachea instead of the esophagus. By this time the student is anxious, but the instructor facilitates the placement. Afterwards, in a private setting, the student is encouraged to critique the experience from his or her perspective. The instructor then reviews the procedure and reinforces learning. However, feedback has only just begun. The next step is for the student to share the experience in the postclinical conference (debriefing). This gives the student an opportunity to acknowledge his or her feelings about what happened and share what was learned. In return, other students are able to share their experiences, ask questions, and provide support. The instructor’s role is to facilitate the team’s learning.
Step 2: Use Structured Communication Tools
Structured forms of communication used to provide feedback can enhance clarity, reduce ambiguity, and signal when action is required (Dayton & Henriksen, 2007). TeamSTEPPS® is an evidence-based program developed in 2006 by the U.S. Department of Defense in collaboration with the Agency for Healthcare Research and Quality to improve communication and teamwork skills among health care professionals (Salas et al., 2009; U.S. Department of Health and Human Services, n.d.). It consists of four competencies—leadership, situation monitoring, communication, and mutual support. The program provides communication tools such as SBAR (Situation, Background, Assessment, Recommendation), call out, check back, briefing, debriefing, and huddle, which provide a standardized structure to improve the way health care providers communicate and function as part of a team (Clapper & Kong, 2012).
The use of briefings, debriefings, and huddles ensures that appropriate time is provided for the feedback process to occur. For example, a morning briefing (traditionally referred to as the preclinical conference) provides an opportunity for educator and student alike to clarify questions such as, “What is the goal of the day?” “What is my role?” and “What are the expectations?” A student who is having difficulty interpreting a blood gas analysis for a patient in respiratory distress performs a call out, which is when the student asks the team (the clinical educator and other students) for help and identifies that the process of feedback needs to occur. A debriefing at the end of the shift (traditionally referred to as the postclinical conference) allows team members to reflect on the day’s challenges, acquire feedback from the other team members and educator, and answer the question, “What did I learn today?” (Shunk, Dulay, Chou, Janson, & O’Brien, 2014).
By introducing students to structured communication tools and providing opportunities for practice, clinical educators can provide feedback and foster team building and a feeling of mutual support among students. Students must learn to give and receive feedback because it is essential for learning, adapting, and providing safe patient care (Dayton & Henriksen, 2007; Jones, Skinner, High, & Reiter-Palmon, 2013).
Step 3: Encourage Dialogue
Traditional clinical learning emphasizes skills checklists and summative evaluations, even though the American Nurses Association’s standards of nursing practice require that nurses solve problems, anticipate problems, analyze situations, and apply information (American Nurses Association, 2010). One of the responsibilities of an educator is to promote those higher order cognitive skills (Davidson, 2009). This requires a more complex interaction than what the sender-message receiver-back to sender communication model depicts (van de Ridder et al., 2008). As a facilitator of feedback, the educator engages the learner in team discussion, leading to dialogue. No longer is feedback a one- or two-way flow of information, but it becomes multidirectional (Cantillon & Sargeant, 2008; Sargeant et al., 2011). Dialogue occurs when individuals freely and creatively explore experiences, actively listen to each other, and set aside their own opinions and biases to explore options and find solutions to problems (Cowan & Arsenault, 2008). The educator leads the dialogue, following a format using the basic elements of feedback—describe what was observed (who, what, when, where, and how); relate how the behavior or scenario made them feel, being as specific as possible and avoid judging or generalizing; and suggest alternative options or another action, behavior, or response based on evidence-based practice (Swihart, 2007). As a team, learners have access to a larger pool of knowledge, have a chance to ask questions and clarify what others are saying, and can reinforce their own knowledge or performance (Arnold, 2010).
The next level of team communication is collaboration, which is a process of communication and joint decision making based on shared goals. Collaboration provides a basis and structure on which professional relationships develop (Cowan & Arsenault, 2008). For successful collaboration to occur, dialogue must first take place.
Step 4: Acknowledge the Human Factor
Again, it is time for nurse educators to take another cue from the current health care environment and recognize how human factors affect the safety and performance of students (Institute for Healthcare Improvement, n.d.). The concept of human factors in health care recognizes the relationship between human beings and the systems in which they function. It focuses on efficiency, creativity, productivity, and job satisfaction, with the goal of minimizing errors (World Health Organization, n.d.). The fundamental basis of human factors is that individuals observe and learn information through a process that is complex and influenced by many factors—both intrinsic and extrinsic. Intrinsic factors for the learner may include pride in work, self-motivation, and interest. Extrinsic factors may include grades, expectations of teachers, and the number of clinical hours required (Nasrin, Soroor, & Soodabeh, 2012; Vanderbilt University, n.d.).
When providing or receiving effective feedback, the learner’s personality and temperament cannot be left out of the equation. It is equally important to consider the learner’s background and readiness to change behavior. Experienced clinical educators make the effort to learn the student’s perspectives and their reasons for a specific behavior (Ramani & Krackov, 2012). The emotions, content, and outcomes model takes into account the human factor in the feedback process, which was developed to help raise learners’ insight and self-awareness of their clinical and professional abilities (Krackov & Pohl, 2011). Step one focuses on acknowledging and exploring the emotional reaction to the feedback received. Step two aims to clarify the specific content of the feedback as it relates to the student’s actual performance. Step three seeks to confirm the student’s identified learning and development of an outcome plan to improve performance (Sargeant et al., 2011).
Educators must recognize that students work within a complex health care system that consists of both human–machine and human–human interactions, with the potential for errors arising from either area. By emphasizing evidence-based guidelines and standards of care, educators set the expectation of quality and safety in performance.
Step 5: Embrace a Leadership Role
Clinical nurse educators must actively choose to be leaders and to role model this behavior to learners. A leader must “decide when to include the input of others in the decision-making process, when to remain firm using one’s own judgment, and when to delegate authority and responsibility to others based on their knowledge and unique experiences” (Clapper & Kong, 2012, p. e371). The traditional leader role is one of controlling and is based on the belief that power comes from the position of authority. In the context of the educator as leader and the student as team member, the relationship becomes a partnership to achieve goals in a climate of trust and support. Feedback links the teaching and assessment roles of the educator and demonstrates commitment to the learner (Ramani & Krackov, 2012). Feedback and assessment are closely related and often overlap in terms of purpose and methodology (Cantillon & Sargeant, 2008). Formative assessment occurs through feedback, with the purpose of promoting learning and improving performance. Summative assessment is about measuring a student’s achievement and conferring a grade or judgment on the performance, with the purpose of determining goal attainment and progression (Oermann & Gaberson, 2014).
As a leader, the educator is a role model for both students and other health care professionals. As experienced nurses, educators are expert in technical skills, patient teaching, counseling, monitoring, clinical judgment, collaboration, ensuring the quality of patient care, and working as part of a team (Adelman-Mullally et al., 2013). According to Vanderbilt University (n.d.), educators who embrace a leadership role will:
- Deliver presentations with energy and enthusiasm.
- Use their passion to inspire and motivate students.
- Make the learning experience personal and demonstrate that they are interested in the students’ success and have faith in their abilities.
- Be a coach and get to know the students so they can tailor instruction to the students’ concerns and learning needs.
- Use a variety of learning activities, such as unfolding case studies and team quality improvement projects, as part of the clinical learning experience to prepare students for practice.
- Role model feedback-seeking behavior to improve their own performance.
Providing feedback has been identified as a key determinate of learning since 1969 (Rogers, 1969) and requires that educators practice and reflect on their own performance to become expert clinical leaders (Cantillon & Sargeant, 2008). The current high risk, complex health care environment makes clinical instruction an increasingly difficult challenge for educators. Graduates are expected to be prepared to enter the workforce ready to successfully communicate and practice effective teamwork and collaboration, which includes the provision and acceptance of feedback (Barnsteiner, 2011; Interprofessional Education Collaborative, 2011).
This article provides an expanded five-step approach to guide educators in the provision and receipt of clinical feedback, which traditionally has been provided as a way to learn in the context of clinical care. The expanded approach enhances teamwork and collaboration by implementing a culture of feedback, using structured communication tools, encouraging dialogue, acknowledging the human factor, and embracing the leadership role.