Monitoring progress, managing feedback and making assessment decisions

Introduction

Monitoring progress, managing feedback and making assessment decisions are interrelated activities that are integral to the continuous assessment of practice. These activities are central to and essential in helping students learn through their practice to develop clinical competence. Using the continuous assessment process enables the monitoring of progress continually and the giving of feedback informally and constantly as the learner works alongside the practice educator – even over one working shift, feedback is an activity that occurs many times. There are, however, specific times when formal feedback should be given based on a more detailed examination of progress. As discussed in Chapter 6, when pre-scheduled and pre-planned ‘formal’ formative and summative assessments are conducted, time and opportunities are available to discuss progress with the student, formally give feedback and make assessment decisions based on the analysis of assessment evidence. The practice educator is in a ‘unique position in being able to provide precise feedback to individual students on all aspects of practical professional development’ (Stengelhofen 1993:153). However, if assessment is to be a true learning process, the student should be an equal partner in these activities – progress is monitored jointly through the formative assessment process set up, and the student participates actively during feedback and assessment decision-making sessions. It is important that these activities occur, not only to maintain the integrity of the assessment process itself but also to meet the rights of the student as a learner. Torrance & Pryor (1998) believe that assessment is truly formative only if it involves the student directly in self-assessment.

Managing feedback

‘Managing feedback’ is used in this chapter to signify the activity of holding constructive discussions with the student about clinical experiences that the student and the practice educator have been involved in. Feedback can take place informally as the practice educator works alongside the student, or more formally during pre-arranged feedback sessions. Rowntree (1987:24) considers that this essential learning activity is the ‘life-blood of learning’. There is research evidence that suggests that this ‘life-blood’ is not well sustained – feedback is either not done well or as frequently as needed or, worse still, not at all (Figure 7.1) (Fitzgerald et al 2010, Clynes & Raftery 2008, Neary 2000, Fish & Twinn 1997, Bedford et al 1993). Bedford et al (1993:107) quoted one practice educator on assessment feedback:

Figure 7.1 Often, feedback is not done well or as frequently as needed, or not at all.

… I shy away from having to give criticism anyway. I’ll always go to great lengths not to give criticism, so I’m not a good assessor from that point of view as I’ll always highlight the positive aspects and I’ll tend … not to go into too many details if a student isn’t doing terribly well in certain areas.

As noted in Chapter 6, it is knowledge of the results of performance provided by detailed factual constructive feedback that enables students ‘to monitor strengths and weaknesses of their performances, so that aspects associated with success or high quality can be recognized and reinforced, and unsatisfactory aspects can be modified or improved’ (Sadler 1989:120). Feedback therefore contributes directly to learning through the process of formative assessment.

Constructive feedback not only has an impact on the teaching/learning process but also gives messages to students about their effectiveness and worth – their self-esteem (Gipps 1994). Feedback therefore has an indirect effect on learning by how the academic self-esteem of the student is affected. Coopersmith (1967 in, Gipps 1994:132) defined self-esteem as:

… the evaluation which the individual makes and customarily maintains with regard to himself – it expresses an attitude of approval or disapproval and indicates the extent to which an individual believes himself to be capable, significant, successful and worthy.

A major determinant of self-esteem is feedback from significant others. Consequently, students look to, and indeed expect and welcome, constructive feedback from significant others such as their teachers and assessors (Embo et al 2010, Neary 2000, Phillips et al 2000, Gipps 1994, Bedford et al 1993). Other authors found that students view good clinical experiences to include receiving constructive feedback (Kotzabassaki et al 1997, Bedford et al 1993, Neville & French 1991). What we know about the effects of assessment on motivation tells us that students give up trying if they do not see themselves as capable of success. If they feel relatively worthless and ineffectual they will reduce their effort or give up altogether when work is difficult (Child 1997). On the other hand, people who hold positive self-perceptions usually try harder and persist longer when faced with difficult or challenging tasks.

There are therefore many challenges for the practice educator on how to manage feedback so that it has a positive impact on learning and, more importantly, on the self-esteem of the student.

Managing feedback sessions

The following framework is suggested for managing feedback sessions:

• timing of the feedback session

• format of the session

• involving the student in self-assessment

• using some ‘rules of thumb’ for managing constructive feedback.

Timing of the feedback session

Feedback will have maximal motivational impact on learning if it takes place while it is still recent and therefore still relevant: points and issues raised are therefore more meaningful and alive (Bailey 1998, Gipps 1994); furthermore, the event and its details are fresh and accessible to memory and not distorted with time (Jones 1995). In the clinical setting, if appropriate, this could take place as a running commentary whilst the learner is performing, or as soon as possible after the event. These are used to offer feedback on aspects of practice that are observed by the practice educator. Such opportunistic feedback will thus be situation specific, which ensures that important elements are included. In addition, this lends itself to discussions and demonstrations of how theory is related to practice.

Prompt and timely feedback gives the learner the opportunity to act upon feedback as soon as possible to improve future performance. A quote from a first-year student nurse in Neary’s (2001:8) study illustrates this point:

I was nervous because [practice educator] worked with me all week and right away she told me where I was going wrong. She responded quickly by helping me to understand what I needed to learn. [Practice educator] did not waste any time in telling me how and what to do. I like that, I know where I need to improve … I can respond to this level of feedback. I feel more confident now; I can get on with the job.

The practice educator who works alongside the student should take advantage of this unique position in being able to offer accurate and timely feedback on all aspects of learning: opportunistic feedback is a vital element of the clinical learning experience.

Feedback sessions after the event will be more beneficial if the practice educator takes the responsibility for making time available and arranging a suitable venue (Gomez et al 1998). It will not be conducive for engaging in constructive feedback if either the practice educator or the student is still preoccupied with activities on the ward or after a busy clinical shift. The session could then prove to be counterproductive. It is important to remember that feedback must be timely to give the student enough time and opportunities to improve.

Format of the session

The format can be oral or written or both. Students usually look for both. Fish & Twinn (1997) believe that written notes are essential in providing continuity in the monitoring of progress. When written notes are kept, the valuable details of the situation are not forgotten, which increases the potential for learning (Bailey 1998). Within the continuous assessment process of pre-registration of health care students, written records of sessions reviewing progress are generally required. Constructive feedback sessions may be used to review progress formally and written records kept of these sessions.

Involving the student in self-assessment

The importance of asking for the student’s self-assessment before giving feedback cannot be underestimated as it provides the practice educator valuable insight into the student’s own perceptions of performance and learning that had taken place. The process of delivering constructive feedback is considerably easier when personal practice limitations are identified by the student. There is more detailed discussion on student self-assessment in the sections on formative assessment in Chapter 6, and the section ‘Discussion with the student’ below.

Using some ‘rules of thumb’ for managing constructive feedback

It is essential that constructive feedback is managed systematically and with discipline. The following rules of thumb for the management of constructive feedback are based upon and extended from the work of Bailey (1998), Fish & Twinn (1997) and Paul (1988):

• Prepare for the session remembering that feedback should not occur in a vacuum but on the basis of explicit aims or objectives of the placement (Billings 2010). When you need to engage in constructive feedback with another person, it generally means that there is some aspect of the person’s performance or behaviour that you perceive is a problem and that you wish the person to correct (Paul 1988). You need to think carefully about what you want the outcome to be; this means that you need to be able to specify exactly what you want the other person to do or to stop doing. If you cannot do this, do not attempt the session as it means that you are not clear enough about what the problem is. You then run the risk of ending up making generalized statements, which frequently offend.

• Keep your appointment with the student and give him/her your undivided time, attention and interest – do not look at your watch constantly. Allocate sufficient time.

• Use a quiet venue and maintain privacy. Be careful not to be interrupted or distracted.

• Do not tackle too many things at once – try to foster a sense of progress. Gipps (1994) says that the most effective forms of feedback are those that focus students’ attention on their progress in mastering the required performance. This emphasis tends to enhance self-efficacy and encourages effort attribution.

• Always try to make the session a learning situation for the student. Be positive as a first step. Just as important as identifying areas of weakness is identifying areas of relative strength. Temper negative comments with praise – the so-called ‘praise sandwich’ (Hinchliff 2004). Rowntree (1987:45) quoted the pioneering chemist Sir Humphrey Davy, who wrote of ‘the love of praise that never, never dies’. Students tend to remember the negative rather than the positive – good points therefore need reinforcing. Help the student to see negative comments as points for growth.

• Use evidence from episodes of practice in as objective a way as possible. Stick to facts and present them in as neutral a way as possible. Use any written evidence from the student’s portfolio to provoke discussion.

• Avoid generalizing and making subjective comments. A statement such as ‘you were brilliant’ may be pleasant to hear, but does not give any detail to be useful as a source of learning. Try to pinpoint what the student did that led you to use the label ‘brilliant’. Praise effort and strategic behaviours and focus students on learning goals; this will lead to higher achievement than praising ability or intelligence, which can result in a learned-helplessness orientation (Nicol & McFarlane-Dick 2005). However, the praise must fit the achievement; overzealous praise may cause embarrassment or be considered insincere.

• Do not compare with other students.

• Above all, remember that criticism is usually counterproductive.

• Be clear about your role – that of being an assessor giving constructive feedback on practice. It is your responsibility to establish communication, clarify any problems and either get a commitment for change or offer a solution (Paul 1988).

Establish communication (Figure 7.2):

Figure 7.2 Smile, make eye contact and listen to the student.

• Use positive and warm non-verbal communication. Smile. Make eye contact. Do not be confrontational.

• Listen to the student. Get the comments and ideas from the student. Asking makes the student feel valued and is better than telling. You may become aware of facts and circumstances that you were not aware of; these may cause you to change your mind about the problem or the nature of the problem.

• Work with the student not on her or him. Avoid a power struggle. Do not take control of the situation.

• Giving negative feedback or leading the student to focus on the things that did not work is also important and should not be avoided. It is tempting to avoid unsatisfactory work, but performance will not improve without knowledge of what was wrong. Remember that there will come a time when it may be too late to give negative feedback.

• Use open-ended questions and give reasons for your questions and comments.

• Encourage frankness and share worries and uncertainties – we are all learners. Remember that feedback works best when a climate of trust exists between the giver and receiver.

Clarify Any Problems:

• Always take account of as many dimensions of the practice situation as possible. Try not to be biased by your own strong reaction or views about any individual part of the situation as this might colour the feedback session.

• If the student counterattacks, do not rise! Try to see it from the student’s point of view – take account of the student’s prior experiences, interpretations and perceptions of what has happened. Explore and clarify what the student is saying.

• Be prepared to see that your own and perhaps different value-base and skills are only of indirect importance. You are not trying to cast the student into a mould of yourself but rather, within professional parameters, to help the student be more fully herself or himself.

• Once you have a clear picture, state the problem in specific terms. Focus on behaviour and facts and not on opinions, personalities and generalities (Paul 1988). For example, instead of saying ‘I wish you’d do something about the way you respond to patients, you do not seem to care’, state the facts and behaviours: ‘Yesterday, I noticed that Mrs Bell had to press her buzzer three times over 15 minutes before you got up from the nurses’ station to respond to her. Today, when you were talking to Mr Hunt you did not make any eye contact and I thought you gave an abrupt answer when he asked you a question. You were also frowning all the time.’

Get a commitment for change or offer a solution:

• Ask the student how performance can be improved. The only way to tell if there is learning consequent to feedback is for students to make some kind of response to complete the feedback loop (Sadler 1989). Unless students are able to use feedback to produce improved work (to improve upon a similar/same aspect of care), neither they nor those giving feedback will know that it has been effective.

• You may need to show how performance can be improved. Be specific: offer alternatives. Avoid suggesting that there are simple right answers. Suggest a small new target that will lead to success.

• Make sure the student understands what is expected by asking the student to say what she/he will aim for and what first steps will be taken. Without this commitment, there is the possibility that nothing will happen.

• You may wish to make a written agreement with the student in the form of an action plan. Within this, set clear targets for the next period of supervised practice.

Readers are directed to the training package by Paul (1988) for some more information on how to give and receive constructive criticism.

Monitoring progress

Monitoring the progress of students is an essential part of the continuous assessment process. Progress can be monitored most accurately if there is continuity of supervision by the same practice educator. The same practice educator is better placed for keeping abreast of the clinical activities the student has had and will therefore know the amount of learning the student has achieved and how the competence of the student is developing. Monitoring progress is an ongoing assessment activity and takes place throughout the duration of the student’s placement. Monitoring in this context, and not ‘policing’, is viewed as a process to help student learning, development and progression. We need to keep track of whether the student is developing competence and achieving the statutory competencies for professional practice. We therefore need to consider carefully what the student is learning, the clinical activities the student has been participating in and how further learning can be facilitated. When monitoring the progress of the student it is important to consider the prior clinical experiences of the student, the competencies and learning outcomes that the student needs to achieve during the placement and the stage of training the student is at. Curriculum documents will frequently state the expected level of performance at a specified stage of training.

When monitoring progress, the role and responsibilities of the practice educator centre on answering these key questions:

• What has the student done and learned so far? How will I know?

• Is the student having any difficulties? How will I know?

• What can be done to facilitate further learning and development?

To obtain answers to these questions, the assessment activities shown in Figure 7.3 are suggested.

Figure 7.3 Assessment activities to monitor progress.

Observation of practice for developing levels of competence

In Chapter 4 there is a detailed discussion of how observation may be used as a method of assessment to obtain direct evidence of the ability to perform care activities. When monitoring the progress of students during observation of their practice, the practice educator needs to gather evidence of:

• continuing safe and accurate performance of care activities with increasing speed and dexterity as the student engages in more clinical experiences and gains confidence

• the development in the level of a student’s competence from the outset of a placement and at its conclusion (Bedford et al 1993).

What we know about the nature of expertise tells us that there are well-defined characteristics, across domains, that differentiate the performances of experts from novices (Benner et al 1996, Glaser 1990, Benner 1984). Glaser (1990:477) sums up the situation thus:

As proficiency develops, knowledge becomes increasingly integrated, new forms of cognitive skills emerge, access to knowledge is swift, and the efficiency of performance is heightened.

Glaser puts forward the case that, with growing proficiency, the changes in a person’s cognitive ability and psychomotor performance can define criteria by which competence can be assessed. The Dreyfus model (in Benner 1984) considers that, in the acquisition and development of a skill, a learner passes through five levels of proficiency: novice, advanced beginner, competent, proficient and expert. As a learner passes through these levels, there are corresponding changes in three general aspects of performance. First, there is a move away from reliance on rules and principles to the use of past experience to guide practice. Secondly, the learner begins to see a situation less and less as a combination of equally relevant bits and more and more as a complete whole in which only certain parts are relevant. Thirdly, the learner becomes an involved performer and engages in the situation.

Benner et al (1996) and Benner (1984) applied the Dreyfus model to the study of skills acquisition in the practice of qualified nurses. They are careful in stating that skills in the nursing context refer exclusively to skilled nursing interventions and clinical judgement skills in actual clinical situations and not to psychomotor skills or to other skills learnt in the laboratory setting. For the purposes of this discussion, a summary of the performance characteristics from the work of Benner et al (1996) and Benner (1984) at the levels of development of the novice, advanced beginner and competent will be made here. Although these characteristics are derived from the performance of qualified nurses, it is my view that they can be extrapolated to the developing performance of pre-registration students. Following this exposition, the characteristics of the knowledge base with increasing proficiency described by Glaser (1990) are summarized.

Knowledge base

Glaser (1990) notes that, as competence in a domain grows, the person displays a knowledge base that is increasingly coherent and useful. The characteristics underpinning these descriptors are described briefly here.