By Debra L. Gist, MPH, FACEHP, Director of Education and Professional Development, American Epilepsy Society
“Negative feedback isn’t always bad and positive feedback isn’t always good. Too often, they say, we forget the purpose of feedback. It’s not to make people feel better; it’s to help them do better.” — A. Tugent, New York Times1
Living animals — humans included — are constantly learning just by interacting with their environment. However, even humans do not always realize that learning is a constant state. For example, a woman might ask herself if there is a better route to her workplace and trials a new driving route. She finds that this new route shaves 15 minutes off her regular commute time and is less stressful due to lack of gridlock. She repeats taking this new route a number of times and continues to receive positive reinforcement and permanently changes her driving route to work.
In 1938, B. F. Skinner’s book “The Behavior of Organisms”2 was published, and following that publication he embarked on many decades of studying his theory of operant conditioning and its relationship to both animal and human behavior. Behaviorists such as Skinner might describe the aforementioned example of learning as operant conditioning. The example includes a question (stimulus) and an answer (feedback), which is positively reinforced and ultimately results in permanent behavior change. The following lessons can be gleaned from Skinner’s research and writings:
- Practice should take the form of a question (stimulus), which, when answered (response), results in a consequence (feedback).
- The learner must respond to every question and receive immediate feedback.
- The question-answer-consequence sequence should expose the learner to the subject in gradual steps.
Other learning theorists might label the above tenants as formative assessment or on-going or in-process evaluation of learning. There has been a slew of educational theorists who have studied feedback and learning and do not subscribe to the behaviorist theory. It is not within the purview of this article to review all of those many theorems and their related body of research. Rather the purpose of this article is provide evidence for the importance of feedback and tips and applying these to the continuing professional development of health care professionals.
Simply put, feedback is a powerful strategy in the acquisition and retention of knowledge, no matter what theorem it is based on. In 1999, Kluger and DeNisi conducted a meta-analysis of studies on feedback. These researchers found that the groups who received feedback outperformed the control groups by 0.41 standard deviations. Interestingly, they also found that the type and timing of feedback were important in achieving such results.3
An example of how powerful feedback or formative assessment can be is found in a meta-analysis of feedback in the classroom conducted by Hattie and Timperley (2007), which revealed feedback is 50 percent more powerful than other factors (such as the use of calculators and homework assignments) in influencing learner achievement. As a result of this meta-analysis, Hattie and Timperley synthesized a feedback model. Their model utilizes the lens of formative assessment and includes the following3:
- Learner receives information on whether or not their answers are correct and incorporates the feedback with additional information, explanation and resources.
- Learner is made aware of the strategies that were used or could be used in arriving at the correct answer.
- Learner conducts self-evaluation.
- Instructor provides feedback to learner (“good” or “smart”).
Not surprisingly, the last item listed above doesn’t seem to particularly draw the learner’s attention to their learning.3 A good addition to the list would be that instructors need to keep in mind that the learning environment, inclusive of feedback, needs to be safe for the learner. Only the learner and the instructor should be able to access the learner’s performance data.
Do these feedback principles apply to health care professionals either in training or in practice? In a study of 340 pharmacy students, 98 percent agreed that an essential part of the program was the feedback they received, and 80 percent felt that the feedback enhanced their performance.3 From personal experience, I’ve seen changes in physician motivation and actual practice as a result of physicians receiving data on their performance and how well their performance compared with those of their peers (aggregate data only). Feedback is powerful!
These findings on feedback can help continue professional development in educational design (science of learning), because there is a definite need to move the profession forward in providing educational interventions that result in improved performance or behavior change. Consider for a moment the learning that took place for the woman who changed her driving route to work; the feedback was powerful and positive (decreased commute time, less gridlock); feedback was immediate; and the learner was in control.
- Tugend A. You’ve been doing a fantastic job. Just one thing... New York Times [online]. April 2013.
- Skinner, B.F. The Behavior of Organisms: An Experimental Analysis New York: Appleton-Century. 1938.
- Hattie J, Timperley H. The power of feedback. Review of Educational Research. 2007:7781.
- Brookhart, Susan M. (2008-09-15). How to Give Effective Feedback to Your Students (Kindle Locations 68-74). Kindle Edition.
- Hall M, Hanna L, Quinn S. Pharmacy students’ views of faculty feedback on academic performance. Am J Pharm Educ. 2012; 76: Article 5.