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Review

Use of Effective Feedback in Veterinary Clinical Teaching

by
Amanda Nichole (Mandi) Carr
1,2,
Roy Neville Kirkwood
2 and
Kiro Risto Petrovski
1,2,3,*
1
Davies Livestock Research Centre, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA 5371, Australia
2
School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA 5371, Australia
3
Australian Centre for Antimicrobial Resistance Ecology, School of Animal and Veterinary Sciences, The University of Adelaide, Roseworthy, SA 5371, Australia
*
Author to whom correspondence should be addressed.
Encyclopedia 2023, 3(3), 928-946; https://doi.org/10.3390/encyclopedia3030066
Submission received: 22 June 2023 / Revised: 24 July 2023 / Accepted: 26 July 2023 / Published: 28 July 2023
(This article belongs to the Section Medicine & Pharmacology)
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Abstract

:
Feedback is essential for the development of veterinary medical learners. This review explores the theory and practical use of feedback in the modern clinical teaching environment. Our purpose is to assist veterinary teaching institutions engage in effective feedback exchange between instructors and learners. Based on literature evidence, quality feedback requires training for both learners and instructors. Effectively executed feedback should be a powerful learning and teaching tool in the development of competencies of the learner. Following the theoretical discussion, we propose a method for delivering scheduled feedback sessions to veterinary medical learners. This differs from ‘on-the-go’ feedback during each clinical encounter, which we have discussed in a previous article related to the use of the five microskills in clinical teaching.

1. Introduction

The aim of clinical teaching in veterinary medicine is to prepare graduands to meet required day-one competencies. Assisting veterinary learners in the development of their veterinary medical and professional attributes requires exposure to practice (work-based learning), in which they work within the clinical context of the institution [1,2]. A common misunderstanding is the term ‘clinical teaching’ being applied only to the exposure to practice. Indeed, clinical teaching can be used in any teaching (e.g., practicals and tutorials). Clinical teaching is essential for development and application of ‘clinical reasoning’ by veterinary medical learners. Methodology used in the delivery of the clinical teaching can be used in other aspects of veterinary medical education [1,3,4]. An essential element of clinical teaching, as in any other competency-based methodology, is the provision of regular feedback on the acquisition of attitudes/knowledge/performance (hereafter competencies) by the learner [2,5,6,7,8,9,10,11,12,13,14]. Indeed, some argue that the skill of providing feedback is second in importance only to clinical competence [15,16]. Further, it should be realized that bi-directional feedback is a great facilitator in the development of instructors [17]. Medical and veterinary education accrediting processes recognize feedback as essential to the development of the learner (e.g., in medical education, the CBME (competency-based medical education) through accrediting bodies, such as Accreditation Council for Graduate Medical Education (ACGME) [10,18,19,20,21,22]; in veterinary medical education, the CBVME (competency-based veterinary medical education) [12,23] and EAEVE (European Association of Establishments for Veterinary Education) [24] through accrediting bodies, such as VSACC (Veterinary Schools Accreditation Advisory Committee), for Australasia). To assist in learner development, the provided feedback should be effective, of high quality and standardized across instructors and time [9,13]. The only way to ensure standardization is the training of instructors and/or provision of guidance templates. Learners have to use feedback in their development. For a better receptivity and increased actionable outcomes on the feedback provided, learners should also receive appropriate training.
In this review, we provide a description of the meaning of effective feedback and how it can be utilized in improving the veterinary medical learner’s experience during exposure to practice, or any other form of clinical teaching. Unfortunately, as with many other areas of veterinary medical education, there is a dearth of evidence-based literature in this area. Hence, we used knowledge derived mainly from the medical education and the experience of the authors in creating a review that we hope can be useful for veterinary medical education purposes. This review is not a comprehensive discussion of the literature but is mainly a summary of the literature integrated with authors’ experience. We would like to note that in this review, when we use the term feedback, we mainly address the use of feedback as a formative, and not summative, assessment. It was not our intention to lower the importance of the summative assessment in learner development, but rather address an aspect that is barely discussed in veterinary medical education. Similarly, our intentions with this review were to concentrate on the provision of feedback by the instructor. Peer feedback in the veterinary medical education sector has been previously addressed [25].

2. What Is Feedback and Its Purpose in Veterinary Medical Education

The primary purpose of feedback in veterinary medical education should be to improve the learning experience and capacity of veterinary medical learners using bi-directional dialogue. If feedback is to be bi-directional, it should be utilized to improve teaching delivered by instructors at the same time. Both elements are frequently mentioned in the cited literature. However, the available definitions of feedback often ignore the second element, the effect of feedback on teaching. Herein, related to the context of this review, we will try to define effective feedback addressing effects on learner and instructor. Feedback is a purposeful, interactive and supportive discussion between the learner and instructor within a context and a culture. The aims of the feedback are assisting the learner in reducing the gap in their competencies [2,5,6,10,11,15,19,20,21,26,27,28,29,30] and also improving the teaching of the instructor [31,32]. Feedback is accepted as being a keystone of the learning circle (Figure 1) and is important for decreasing the heavy workload in curricula [33]. It can be essential to evoking response and change by the learner, aiming to correct misconceptions and also to reinforce sound competencies [5,6,10,13,14,17,29,34]. Indeed, improvements in competencies of the learner are only possible when the feedback is effective (Figure 1) [15,25,28,35,36,37]. With the aim of enhancing the learner’s competencies, feedback must be offered in a constructive manner, using descriptive rather than evaluative language, in addition to being Specific, Thoughtful, Actionable, Timely, Individual and Criterion-referenced (mnemonic STATIC) [3,5,15,19,35] or specific, timely, objective/observed, and planned for improvement (mnemonic STOP) [38]. The previous specific, thoughtful, actionable, and timely (STAT) format of effective feedback [16] lacks tailoring to the learner benefits. Hence, we propose an extension with two additional elements, individualized (I), and criterion-referenced (C), becoming STATIC. In medical education, provision of effective feedback has been associated with many improvements [29,39], including better diagnostic and treatment skills [2,5], better developed record keeping [5], and lowered need of ancillary testing [5].
Feedback can engender a stimulating and positive response by a learner, resulting in the acquisition of new competencies (cognitive aspect) [2,5,7,11,18,32,40,41,42,43] and is essential to metacognition [12,32,39,44]. Ultimately, effective feedback helps the learner but, as veterinary medicine is a professional degree, feedback is essential for the benefit of the client/patient and maintenance of the professional image. However, feedback, particularly when not effective, may result in loss of motivation, a negative response, and stress for the learner [2,5,11,40,41,43]. In the absence of effective feedback, impediments in reaching competencies should be expected [5,6,16,18,27,38,39,43,45,46]. Without effective feedback, mistakes/omissions are not corrected and good competency is not recognized and reinforced, ultimately slowing down the development of the learner [15,16,26,39,43,45,47,48]. Additionally, without effective feedback, some learners may be self-delusional regarding their competencies [38,49]. However, this does not mean that every learner is unconditionally provided with feedback. Feedback should be given only when the learner is willing to receive it [5]. Furthermore, feedback should not be used to fill large gaps in knowledge of a learner. Learners with large gaps in knowledge may be better dealt with through didactic approaches to teaching rather than feedback sessions [39].
Historically, feedback has been instructor-centered with the instructor passing a message to the learner [18,19,26,34,47]. In the past 2–3 decades, as a result of changes in social interactions, the feedback has become an interactive, supportive discussion between learner and instructor as part of the ‘feedback culture’, aiming to stimulate self-reflection, deep learning, and the learners taking responsibility for their own learning [2,18,19,26,32,34,38,49,50]. These are steps ensuring the learner is prepared for life-long learning.
A common misconception is that feedback is equivalent to assessment [2]. Although feedback may be carried out in conjunction with assessment, effective feedback should be used both continuously (on-going) and scheduled (periodic), and not reflective of an assessment performance only. Ideally, feedback should be a formative task (related to assessment for learning), rather than a summative (related to assessment of learning) task [2,15,19,38,47,48]. Properly executed, feedback should be providing information on competencies rather than giving a summative score without information accompanying it [5,15,19] (Table 1). A summative score does not inform the learner of their specific competency, but effective feedback does [5,19,36,39].
Many of the procedures carried out during clinical encounters in veterinary practice are irreversible and may affect safety and outcomes for the client and/or patient. This is a complicating factor to the provision of effective feedback to veterinary medical learners [2,11].

Types of Feedback

Types of feedback categories and their basic description are presented in Table 2. However, the categorization is not set in stone. For example, the duration of the feedback session should allow for an interactive discussion and should not be rushed [15] or artificially prolonged [15,18,52]. Detailed descriptions of the role of each type of feedback mentioned in Table 2 is beyond the scope of this review.
Feedback can be also divided by the reason for delivery, as presented in Table 3 [6,10,18,19,32,34,51]. In this review, we will concentrate on bi-directional coaching by both veterinary medical learners and instructors.

3. Barriers to Efficacy of the Provided Feedback

Using predominantly medical education literature, barriers to efficacy of the feedback given to veterinary medical learners include those presented in Table 4. Some of these barriers result in the lack of recognition of feedback, others in low quality of feedback, non-receptivity by the learner, or avoidance of provision of feedback. Barriers presented in Table 4 usually demotivate and/or embarrass the learner, and may lead to an emotional response [5,13,27,28,53,54]. The usual working memory of a person retains only 7 ± 2 items at any given time [21] but works the best with 3 ± 1 items at a time [55]. Therefore, when the amount of discussed information is more than 2–3 actionable points, learners forget many of the discussed points or they concentrate on what, in their opinion, is important [21].
The common misconception that in the busy clinical setting, there is insufficient time for observing learners and the provision of effective feedback can be minimized by using clinical teaching methods that have feedback incorporated within them (e.g., the Five microskills model [4]) or by detailed observation based on brief assessments (e.g., brief structured observation [56]). Training will improve some of the feedback environment/delivery areas. Despite the belief of corrective feedback having a negative effect on learner–instructor feedback, medical learners have stated that they understand that this is only one element of the everyday relationship [13]. Some of the barriers are mitigated by a longer and nurtured instructor–learner relationship [31].
Table
Table 4. Known barriers to effective feedback.
Table 4. Known barriers to effective feedback.
Area of FeedbackParameterReferences
Feedback content/contextAddressing issues that cannot be corrected, volume of information (e.g., overwhelming)[16,38,43]
Assessment/Summative information rather than coaching, lacking intervention plan[5,6,15,16,18,19,27,51]
Attempts to interpret learners’ intentions rather than stating facts, insensitive, mismatch in the quality of provided/received feedback[39]
Focus on learner/personality traits rather than performance, unidirectional (instructor-based)[5,6,15,18,19,28,39,43]
generic (e.g., not based on direct observation, not addressing specific competency), nontailored, inconsistent, late[5,15,18,19,21,26,27,28,36,38,39,43,52,57]
Feedback delivery/environmentCommunication issues (e.g., language primarily composed of adjectives and adverbs, technical language, English as a second language)[5,6,15,18,19,39,52]
Difference in age, culture (including lack of ‘feedback culture’)[43,57]
Difference in power, no established learner–instructor relationship, proud maintenance of hierarchy[8,11,16,19,27,31,43,49,52,57]
Not suitable for provision of feedback (e.g., confrontational furniture setting, not ensuring confidentiality)[5,13,18,19,22,50]
Overall learning environment not supportive of the feedback process, stressful clinical environment, time constraints, workload issues[8,13,16,17,22,26,43]
Instructor (Provider)Belief that learners are not interested in receiving effective feedback in improving their performance and are only concerned about the grade, cognitive biases (e.g., ‘halo’ effect, unconscious bias)[2,18,37]
Insufficient baseline knowledge of the instructor, lack of experience/expertise in providing feedback, lack of training in the provision of effective feedback, being dishonestly kind when there is need of improvement[3,19,21]
Difference in the perception what constitutes effective feedback, inadequate attitude, poor availability to learners, incongruity with the learner’s perception of feedback[2,5,11,20,22,33,47,48,57]
Fear of interpersonal tension in instructor–learner relationship[5,11,13,15,19,20,22,28,43,48,58]
Fear of emotional reaction by the learner, fear of retaliation[2,5,7,8,13,14,15,18,19,28,29,43,48,52,57,58]
Preventing learner-centered approach to feedback, inappropriate language/expression[8,18,50,52]
Unknown expectations (e.g., no mutually agreed-upon learning outcomes, poor curriculum knowledge), lack of direct observation[18,38]
Learner (Receiver)‘Halo’ effect (cognitive bias, in which overall impression changes perception towards favorably perceived learners)[17,19]
Incongruity with the instructor’s perception of feedback, lack of recognition feedback has been provided, unknown expectations (e.g., no mutually agreed-upon learning outcomes)[2,5,7,13,14,15,16,18,20,22,29,33,38,48]
Lack of self-awareness/efficacy, lack of psychological safety to contradict feedback information, early in training[13,48]
Not receptive to feedback, emotional state, overconfidence, personal disposition[5,13,18,43,52]
It is a common belief that tertiary learners are never happy with the level of provided feedback. This is a frequent report in medical education [2,5,7,8,11,15,28,29,35,42,48,50]. However, instructors often disagree with these student comments [2,15,18]. Authors of this review have similar experience with the student evaluation of learning and teaching (SELT) resulting in discontent by instructors believing that provision of feedback has been frequent and useful. The discrepancies may occur due to a number of factors. The lack of a clear identification of the discussion as feedback may occur due to provision of ‘on-the-go’ feedback (e.g., omission in competencies) being perceived as the ‘provision of feedback’ by the instructor but having no meaning to a learner as it often lacks specifics and instructions on how to improve. Therefore, any discussion that has elements of feedback should be explicitly labelled [2,16,18,38,39,48] either verbally (e.g., ‘I would like to give you some feedback on your performance at the last clinical encounter’) or using pocket cards with the side visible to the learner clearly stating ‘This is a feedback’. Discontent with the provision of feedback can be mitigated by a longer and nurtured instructor–learner relationship [31].
We would like to point out that all these barriers cannot be completely avoided, e.g., it is often difficult to separate the performance from the individual [5]. A lack of interest in the learner’s competencies may be assumed when feedback is generalized [27]. When feedback is not effective, the learner may not act on the feedback or lack internalization and recognition of the provided feedback [26].

3.1. Elements of Effective Feedback

What represents meaningful feedback is not well established [8]. In human medical education, quality of feedback has been an interest of a number of studies, but the results are not consistent and often confusing [20,21,27,35,39,42]. One large study, based at a single university, reported more than 80% of written feedback provided in an electronic form as being not effective [27]. The skills of providing feedback have accounted for over 50% of the perception of the feedback quality [16,39]. Consistency of feedback and standardization of feedback sessions have also been stated as important by both providers and receivers of feedback [39]. A good meta-analysis in this area will clarify some of the discrepancies and contribute to the urgent need of research in this area in veterinary medical education.
Elements of effective feedback are presented in Figure 2 (data extrapolated from [2,4,5,6,7,8,9,10,11,13,14,15,16,17,18,19,21,22,26,27,29,31,32,35,36,37,38,39,40,42,43,46,47,48,50,51,52,53,54,59,60,61]), with a mention that continuous longitudinal feedback is the best [26]. Some elements of effective feedback are regularly iterated, but they are not always black and white. The timing of effective feedback is often stated as needing to be immediately related to the activity, although there are situations when this is not true. For example, providing negative, even constructive criticism, in front of a client may damage the learner’s confidence/motivation/willingness to continue the development [5,17,43]. Effective feedback is usually given individually. However, if the entire group benefits from a single feedback session, group-level feedback can be provided [39]. In such a case, sensitivity to the feelings of the individual learner is essential.

3.2. Who Can Initiate the Feedback Session

Feedback should be provided regularly to learners, which is best organized by scheduling feedback sessions for each learner at the start of the activity (e.g., start of the work-based experience) [2]. However, feedback may also be given on the go/in real-time. Feedback session may be initiated by the instructor [5] or the learner [5,8,11,15,43,48,52]. For this purpose, the learner may need training in soliciting feedback [15,19,27,43,52]. The learner’s solicitation of feedback may be inhibited, particularly in the earlier stages of development, due to the fear of criticism on suboptimal competencies [16]. Additionally, clinical teaching relying only on learner-solicited feedback may result in feedback being requested only when the learner is of opinion that they have done well or from an instructor they believe will provide only positive feedback, ultimately resulting in false economy and impediments in learning [14,27,54].

3.3. Who Can Provide Feedback to Veterinary Medical Learners

Feedback can be provided by an external agent (e.g., client, instructor, peer, support staff, or other involved parties) but can also be self-generated [6,8,11,17,18,33,39,43,50,52]. Self-generated feedback is an important component of deep learning, as it evidences metacognitive approaches. Learners should be encouraged to seek feedback from multiple sources [43,52] and this should be a culture within the environment. Feedback from multiple sources may result in more relevant/timely feedback for the learner [43]. However, some learners may become a nuisance by asking everyone to provide them with feedback. Training in seeking feedback may prevent problems of this nature. Additionally, there is a danger of the learner being provided confusing or incongruent feedback.

4. Feedback Context (Content and Style of Delivery)

The context of effective feedback should address a specific competency based on direct observation using non-judgmental language and having a clearly designed action plan [19]. Agreed-upon learning objectives and/or curriculum-specific outcomes and/or day-one competencies should be used to frame the context of the effective feedback [19]. When constructive criticism is used in effective feedback, it should be clear, empathetic, fair, and honest [19]. The action plan should be mutually agreed upon and followed until execution [19]. Writing down a summary of the feedback or, alternatively, providing written feedback may serve as a memory jogger and improve retention and application of feedback-related information [47]. Individualized feedback is a must and the level of feedback content should match the learner’s capacity. For example, novice and low-achiever learners may benefit more from directive feedback and instructions rather than the stimulation of meta-cognitive abilities [62]. The context of effective feedback must also consider the focus, addressing only a few items at a time [19].

5. Environment for Providing Feedback to Veterinary Medical Learners

‘Feedback culture’ within an organization (e.g., clinic, hospital, or university) includes ensuring regular, quality feedback is provided from direct observations and that regular refresher courses are organized for all involved parties [17,19,28,48]. Most organizations with good ‘feedback culture’ have included peer-feedback systems [19]. Learners receiving feedback may feel very vulnerable, and modern education literature indicates the need of fostering psychological safety of learners in tertiary education [19,39,40,48,50,54]. Minimizing the effect of the environment on the impact of the feedback is important for learning and, in organizations with a ‘feedback culture’, feedback is always provided in a ‘safe environment’ (Figure 1).
Defining a ‘safe environment’ is not an easy task. In brief, a safe environment is where learner–instructor conversations allow for the freedom of expression in a confidential setting, away from teaching and without distractions, but also allows the learner to take risks [2,8,39,40,48,50]. Privacy of the dialogue, particularly from external persons (e.g., clients) and peers should be ensured whenever possible, particularly when discussing areas needing improvements [16,17,38,43]. The ‘safe environment’ should allow for adjustments tailored for individual learners to their level of confidence and knowledge [40], capacity for admission of mistakes [19,40], exchange of ideas [40], peer learning [40], provision of feedback [40], risk-taking [19,40], and seeking assistance as required [40]. Only in such an environment can learners develop without hesitations and receive feedback without embarrassment [15,17].

6. Instructor

The instructor’s response to providing feedback may be positive or negative. A positive response to providing feedback is usually seen when, following a feedback session, improvements in learner’s competencies are evidenced. A negative reaction is usually the result of the belief that feedback on suboptimal competencies would elicit a negative reaction from the learner (e.g., emotional response, fear of retaliation (e.g., complaints, litigation, and poor instructor assessments), or risk of damage to the relationship) [13,16,19,27]. Therefore, many instructors choose to be dishonestly kind when there is a need of enhancement in learner’s competencies [19,27]. Currently, many universities may be unkind to instructors, with negative learner evaluations being an important part of the professional development and promotion rounds.
Many of the barriers to feedback are related to an instructor’s performance and personality. It is often the content and delivery of the feedback that result in barriers to feedback. This is rarely intentional, it being more likely associated with lack of feedback literacy [27].
Training of instructors, in the provision of feedback, should improve their confidence in this important function and standardize the format of feedback so it is less confusing to the learner. In short, training should improve the instructor’s ‘feedback literacy’ [61]. Unfortunately, many instructors have received minimal or no training in the provision of feedback [3,13,15,16,30,39,63,64,65,66,67]. The difficulty with the insufficient and inefficient training of instructors is even higher with the increasing number of veterinary schools opting for a partial or entirely distributed model of exposure to practice. Additionally, it is expected for instructors in the distributed institutions to have less experience in the assessment of the progression in clinical competencies of veterinary medical learners and/or the provision of feedback [8,30,40]. Even instructors that have received training in provision of feedback may feel uncomfortable in doing so when learners lack training in receiving feedback [35]. Hence, training in the provision of feedback should be organized for instructors [3,5,6,8,9,10,13,19,20,21,22,27,30,34,35,38,39,42,48,53,56,57,63,65,66,67,68]. It is worth noting that the concurrent training of learners and instructors has shown the best results [29,34]. Similar to learners, improvement in receptivity and/or provision of feedback by the instructor is enhanced with practice [5,18].

7. Learner

Undoubtedly, learners value the provision of feedback, particularly when it is helping them with their development [32,36,37,43,52]. A large variation in the effect of feedback has been reported, partly due to lack of feedback literacy in learners (e.g., capacity to solicit, receive, engage/internalize, and use the feedback; Figure 3) [13,16,32,37,38,50,52,53,54,55,57,61]. Additional factors that should be considered are emotional state, self-regulation, sociocultural/economic background, and stage of the learner’s development [19,21,27,28,37,48,52,54,55,57].
Four triggers have been identified with potential to influence the receptivity to feedback by learners:
  • ‘Experience’, referring to prior experience with feedback. Previous exposure to destructive feedback often results in reluctance to use feedback information [48].
  • ‘Identity’, referring to the belief that one’s personal identity is being assaulted [13,17,21]. Perception of this character is often associated with emotional responses. Emotionally charged situations are not conductive to receiving feedback by the learner [17]. In such situations, feedback should be delayed until the emotional charge has subsided.
  • ‘Relationship trigger’, referring to the learner–instructor relationship and the learner’s perception of the credibility of the instructor [17].
  • ‘Truth trigger’, referring to inability/reluctance of the learner to accept that the feedback information is correct [13,17]. Terms over- and underconfidence are often used to describe this trigger. For example, a mismatch between the provided feedback and self-assessment by the learner (the so-called Dunning–Kruger effect of cognitive bias, in which the learner overestimates their ability in performing a task) [19,39]. Another issue causing this trigger is discordant feedback from a variety of sources. The ‘truth trigger’ becomes more evident with the self-esteem of the ‘Millennial generation’, who see themselves as being special and who lack the ability to self-critique [27].
The learner’s response to feedback can be positive or negative. Negative reactions usually result from feedback on suboptimal performance and misconceptions by the learner as to what the particular competence entails [16]. Overall, a negative response should be expected after feedback of a summative type (judgmental) [6] or as a result of the association of negative previous experience with feedback [6,50]. Positive feedback should build self-esteem in the learner, assist them to actively engage in the process, and stimulate the repetition and enhancement of the praised competency [43,46,50,69,70,71]. Response to feedback may also vary with the learner’s development, being usually more engaging with positive feedback in early stages of development and with negative feedback later [37,52]. Novice learners would benefit more from immediate feedback, while advanced learners often benefit more from somewhat delayed feedback, allowing them time for self-reflection.
Training of learners in receiving feedback improves its receptivity [5,18,25,26,39,50], but, also, the experience [5,26,50,53] results in ‘feedback literacy’, adding to the acting on feedback after internalization [26,50,61]. Hence, training in receiving feedback should be provided to learners [8,19,28,35,52,57]. Unfortunately, compared to the training of instructors, the training of learners is a less frequently discussed area in the literature [19,34,50]. Training can be afforded in the form of workshops and/or the provision of feedback resources (e.g., examples, guides and forms) [3,50,61].

8. Models for Providing Effective Feedback

Effective feedback should be provided with the aim of improving competencies of the veterinary medical learner [18]. Some of the commonly used models for the delivery of effective feedback to veterinary medical learners are presented in Table 5 (information collated from articles [4,5,6,16,18,19,28,34,38,39,43,47,48]). Indeed, all clinical teaching models (e.g., SNAPPS) may be utilized for formative feedback, in addition to others not discussed in this review (e.g., Feedforward model, PEARLS, R2C2 model, Silverman’s SET-GO, The Chicago model, etc.). Detailed discussion of all possible approaches to delivery of effective feedback is beyond the scope of this review.
Traditionally, feedback has been provided in verbal or written form [6,9,47,57]. No differences between verbal or written feedback have been reported [6]. Probably, the same applies to use of other tools for the provision of feedback. However, the provision of written feedback should be carefully crafted, as some cultures may have problem with the vocabulary used in the written expression [5,57]. In the last few decades, computerized tools for the provision of feedback to learners have become available. One example is the system for improving and measuring procedural learning (SIMPL) using a smart phone application, allowing learners and instructors to provide feedback to each other [41]. For remotely located learners, telephone or video feedback sessions have also been proposed and reported as effective [5] as they provide opportunity for interactive discussion [57]. However, e-mail based feedback should be avoided, as it is usually assumed as an informal way of communication [5].
Some of the tools for the provision of feedback are designed for specific tasks only and should not be the sole source of feedback for learners. For example, SIMPL is designed for procedural activities and may not be suitable for assessing the clinical reasoning competency of a learner.

9. Method for Providing Effective Feedback to Veterinary Medical Learners

The optimal method for the provision of feedback is unknown. What is clear in the authors’ opinions and those of the many studies previously mentioned is that timely feedback is essential to the learner’s development. On-the-go feedback should be provided with every clinical encounter or activity using the clinical teaching methodology. Previously, we have introduced one of these methodologies (The Five Microskills method of clinical teaching [4] that is briefly covered in Table 5). However, as learners often undervalue on-the-go feedback, and overall learner’s adherence to agreed-upon learning objectives cannot be always covered in on-the-go feedback, so in-depth feedback sessions should be scheduled. Learners prefer consistent, standardized feedback sessions. We describe below a proposal for the provision of feedback in scheduled feedback sessions.
The proposed guide to providing effective feedback to veterinary medical learners is presented in Figure 4 (prepared using information from [10,15,16,17,18,28,32,38,39,43,44]). Attention to detail is required regarding the content, environment, format, and structure of the feedback session. The content of the feedback session should be limited to only few facts (preferable < 5; avoiding cognitive overload), addressing STATIC principles (specific, thoughtful, actionable, timely, individual and criterion-referenced) [8,15,39,51] with a clear path forward for the learner rather than a simple report of past suboptimal competencies. The environment should ensure confidentiality [8,15,39,43,51] and appropriate sitting arrangements (Figure 5). The format of the feedback session should follow the guidelines presented in Figure 4 [15]. The interactive, supportive dialogue should include self-assessment/reflection by the learner, constructive feedback by the instructor, and a mutually agreed-upon plan of action [15,39]. Self-reflection by the learner allows the instructor to gain insights into the learners beliefs of their current level of development [39]. Having an allocated time for preparation for feedback should allow the learner to prepare for the self-assessment discussion and identify areas where assistance may be required [15,39]. Finally, the structure of the feedback session should ensure awareness of the session and enough preparation time for both involved parties [15,39].
Planning should prevent surprises for the learner but also the omission of the provision of feedback. Both the learner and instructor should be aware that the provision of feedback will be a part of the learning cycle (Figure 1). The achieving of goals is only possible if, at the start of the activity, learning outcomes are clearly stated and are mutually agreed upon. The learner may need assistance with the selection of learning outcomes, particularly when straying for exciting and complicated activities but ignoring Day-one-competency-related activities. Another common problem is that learners try to achieve learning outcomes outside of the scope of the activity.
To set the scene, unless there is a need for urgent feedback (e.g., serious lack in competencies, unsafe activity being performed), the learner and instructor should have time to prepare for the feedback session. This should include reviewing necessary notes and ensuring the calendar allows for an uninterrupted session. The instructor may need to collect information from other people with knowledge of the activity related to the feedback session and the particular learner. As there will be a need to link gaps/mistakes/omissions to day-one competencies/personal learning objectives of the learner, a refresher of these is also advisable. Additionally, the learner should be reminded that the session addresses feedback. A clear statement such as ‘I will be expecting you in half an hour for our feedback session’ prevents misinterpretation of the discussion as an informal chat and clearly identifies it as a feedback session.
The main portion of the feedback session should be reserved for its execution. To orient the learner in the expectations of the feedback, the instructor should provide a description of how the sessions will run, how long it is expected to run, and when they can expect to have the next session. For example, ‘Thank you for coming. Let’s set few ground rules about the feedback session. Usually, the feedback session will start with your reflection on the performance during … and then we will make plans for … I would expect this to take less than 10 min. As feedback is essential to keeping everything on track, we will plan to have the next feedback session in 3 days, at the same place and the same time. Is this OK with you?’ It may be required to limit the area of discussion to 2–3 topics only. However, this may be better achieved after the learner’s self-reflection. For example, ‘We should agree that, to be of being most beneficial for us both, during this feedback session we will restrict the discussion to only 2–3 areas. Trying to achieve more than this is often going to backfire on us. Are we in agreement on this?’.
In the next step, the learner should be asked to self-reflect on their opinion on how they are performing. For example, ‘At the start, of this discussion, I would like to hear how you feel you are/were doing during …’ or ‘Can you let me know what you learned from this …?’ Two separate elements should always be covered: the reinforcement of the good competencies and correction of mistakes/omissions.
It is expected that during the self-reflection, the learner will identify the gap in knowledge/mistakes in performance/omissions in attitude or performance. The recognition should be acknowledged. For example, ‘It is an important learning skill to be able to admit a mistake/omission of this character. Well done’. It is recommended to ensure the learner is aware of the eventual consequences of the suboptimal competency. For example, ‘It is important to keep on mind that an omission of this character could result in …’. Occasionally, a learner may list number of omissions. This should prompt the instructor to use language preventing judgment in a constructive way. For example, ‘You were harsh on yourself regarding your performance’ would be better delivered as ‘Using your self-reflection, what you said sounded a little judgmental towards your performance’. To restrict the discussion to 2–3 areas only, the instructor should use signposting. For example, ‘As agreed at the start of this session, we will concentrate on 2–3 areas only. Can we agree on which of the 2–3 areas we will address at this session? I would like to hear which 2–3 areas, in your opinion, are at the most needing development?’ However, if the learner lacks recognition, the instructor may need to guide the learner in detecting the gap/mistake/omission. For example, ‘Can we discuss on how you think the process of … carried out during …?’ The step involving the learner’s self-reflection is essential to the feedback session and the remaining time of the session should build on this step.
It should not be forgotten that the strengths of the learner in the competency/management of the clinical encounter should be reiterated. For example, ‘I believe that the consideration of the age and hydration status of the cow in the decision on the XX certainly decreased the risks of XX. I think this would be beneficial for XX’.
Corrective feedback should be provided in private settings whenever possible. When privacy cannot be ensured or feedback cannot be delayed, corrective feedback should not be given on front of clients [43]. With the aim to correct gaps/mistakes/omissions, the instructor should ask the learner for their opinion on how this can be managed. For example, ‘OK, if I understood you correctly, you felt that … could be improved… The learner nods in confirmation… I would agree with your statement. It is really good that you recognized this … As we are all in a safe environment, we were all aware that things like this may occur. Let’s think of the future. Is this OK? … Learner nods in confirmation… If you were to do this again, what would you do differently to achieve the projected goals of your learning?’ It is important to stress the importance of the discussion related to day-one competencies and/or personal learning objectives of the learner. For example, ‘I would like to briefly discuss the gap/mistake/performance you identified as needing corrections. How you do you feel this aligns with the Day One competencies/your personal learning objectives we both agreed on earlier?’ The agreed plan of action must be based on mutual understanding of what was criticized/praised [39].
Even if no significant gaps/mistakes/omissions are evidenced, each feedback session should identify at least one area that will be an additional challenge. This will stimulate the learner’s further development and independence. For example, ‘It is obvious that at this session we discussed a lot of the … are close or exceeding expected competencies. I would like to ask you to think of at least one area that would benefit from further development.’
The summary portion of the feedback session should ensure mutual understanding of the feedback and of the plan of action. For example, ‘I would now like to hear, in your own words, a short 2–3 sentences summary of what we discussed and what we agreed on.’ The ending should also ensure the following feedback session is also restated from the orientation of the feedback session. For example, ‘As we agreed previously, the next feedback session will be in 3 days, at the same place and the same time. Is this still OK with you?’
After the session, a summary should be documented, ensuring the agreed-upon interventions are clearly stated. A copy of the documentation should be provided to the learner. The learner’s copy will refresh their memory and, potentially, increase the receptivity. If the mutually agreed-upon plan of action contains any responsibility on the instructor’s part, it is important for this to be followed up on.
The language used during the feedback session should be easy to understand, non-judgmental and stating neutral facts [39,43]. The best approach to providing feedback is to use open-ended questions that would stimulate an interactive, supportive discussion. For example, ‘Can you tell me about your experience with …’ is recommended rather than ‘How did you do during …?’ The second example sentence may yield a single word reply. The use of statements with ‘I’ often provide confidence to the learner since the feedback is based on direct observation. For example, ‘When you were examining the thorax … I thought you were checking for …’. Only clearly explained facts allows for good receptivity of the feedback. Ambiguous statements should be avoided. For example, ‘Continue practicing …’ or ‘Would be good to increase your knowledge base’. Additionally, the use of superlatives should be avoided. For example, ‘I think this was the best performance I have seen to date’.
Feedback may be difficult for the learner. Hence, the settings should allow for outbursts of emotions (e.g., having facial tissues handy). Occasionally, learners may become aggressive, defensive, or tearful [5,39]. The instructor should not intervene until the learner is composed and instead of continuing with the interactive discussion on attitude/knowledge/performance, it is better to switch to preparing an action plan, often seen by the learner as a positive outcome [5]. Dependent on the developments, the feedback session may return to interactive, supportive discussion on other competencies traits of the learner that are worth discussing. In the case of non-receptivity to the feedback by the learner, one of the potential techniques that can be utilized is to ask the learner for self-reflection [39] and rediscussion on the stated facts.
In the case of a need to address multiple competencies in an individual learner, it is better to schedule several feedback sessions rather than overwhelming the learner in a single session [39]. Guidance given to the learner on what is to be covered in each of these sessions will allow the learner to self-reflect.

10. Discussion

Organizations involved with the delivery of clinical teaching to veterinary medical learners should ensure a flourishing feedback culture. For this purpose, learners, instructors and all other personnel should receive training in educational background and particularly in the role of feedback in the development of learners and instructors. The cited literature has often neglected the learners need for training. However, recent educational research has shown that the training of learners is equally, if not more important, for feedback to be effective [37].
The majority of cited literature in this review originates from medical fields. The One Health approach to medical education supports similarities in medical and veterinary medical education. However, significant differences exist between the two areas [12,23]. Therefore, it would be better to have more literature in the provision and/or receptivity to feedback from the veterinary medical field. The lack of studies in the field of veterinary medicine feedback is evident from this review. We are of opinion that this does not result from a lack of interest, but rather, more likely, that the lack of funding in veterinary medical education research is the culprit. Therefore, we strongly encourage organizational support for educational research.

11. Conclusions

Indisputably, the development of clinical competencies in veterinary medicine learners is heavily dependent on effective, high-quality, and standardized feedback. With the aim of enhancing the instructor’s and learner’s performance, feedback must be relevant, Specific, Thorough, Actionable, Timely, Individualized, and Criterion-referenced, given in a ‘safe environment’. The best outcomes are in organizations that have developed a ‘feedback culture’. The training of instructors in education is recognized as important for the quality of teaching. Therefore, for good feedback literacy, instructors should also receive formal training in the provision of effective feedback. At the same time, veterinary medical learners should receive formal training in soliciting and receiving feedback. Organizations where instructors work, including universities, should reconsider the role of the provision of feedback in their professional progression and promotion rounds.

12. Glossary of Terms

Clinical competency (in veterinary medicine)—the ability to select and carry out relevant clinical tasks pertaining to the particular clinical encounter. These aim at resolving the health or productivity problem/s for the client, industry, and/or patient in an economic, effective, efficient and humane manner, followed by self-reflection on the performance, indicating the occurrence of a deep learning. Where applicable, many of clinical competencies are clearly defined by the various accrediting bodies (e.g., American Association of Veterinary Medical Colleges (AAVMC), EAEVE, The Royal College of Veterinary Sciences (RCVS), VSCAAC, etc.).
Clinical encounter—physical or virtual contact with a veterinary patient and/or client (e.g., animal owner, employee of an enterprise) to carry out the assessment of clinical elements, product quality/quantity, or management activity.
Clinical instructor—a person delivering clinical teaching (e.g., apprentice/intern in the upper years, resident, veterinary educator/teacher, veterinary practitioner).
Clinical teaching—methodology of teaching that involves a physical or virtual clinical encounter and interpersonal communication between the clinical instructor and the veterinary medical learner.
Deep learning—aiming for the mastery of essential academic content being empowered through self-directed learning, including but not limited to solving complex problems, thinking critically and working collaboratively.
Effective feedback—purposeful conversation between the clinical instructor and the veterinary medical learner with the aim to stimulate further development of clinical competencies and deep learning.
Feedback culture—organizational structure that allows for and facilitates the exchange of feedback between learners and instructors in a safe environment.
Feedback literacy—enabling the learner to receive feedback, internalize exchanged information, integrate feedback information into their learning, and developing competencies through provision of effective feedback.
Metacognition—critical awareness of one’s thought processes and learning, and an understanding of the patterns of thinking and learning (‘thinking about thinking’).
Proper learning or a safe learning environment—an environment in which a learner feels safe, relaxed, and willing to take risks in pursuing a goal, and which enhances self-esteem and encourages exploration.
Work-based learning—(synonyms: experiential learning; exposure to practice) an educational method that immerses the veterinary medical learners in the workplace.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

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Figure 1. The learning and teaching circle of clinical competencies for veterinary medical learners.
Figure 1. The learning and teaching circle of clinical competencies for veterinary medical learners.
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Figure 2. Elements of effective feedback.
Figure 2. Elements of effective feedback.
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Figure 3. A proposed guide to the bi-directional provision of feedback between learner and instructor.
Figure 3. A proposed guide to the bi-directional provision of feedback between learner and instructor.
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Figure 4. Proposed guideline for providing effective feedback to veterinary medical learners.
Figure 4. Proposed guideline for providing effective feedback to veterinary medical learners.
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Figure 5. Differences in sitting arrangements around a table showing authority (A) or equality (B). Only sitting indicative of equality will allow for effective feedback.
Figure 5. Differences in sitting arrangements around a table showing authority (A) or equality (B). Only sitting indicative of equality will allow for effective feedback.
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Table
Table 1. Benefits of providing veterinary medical learners with effective feedback.
Table 1. Benefits of providing veterinary medical learners with effective feedback.
BenefitsReferences
Enhances
  • Learner–instructor relationship
  • Learner’s
    ○
    Achievement of day-one competencies
    ○
    Best fit with the learning style(s)
    ○
    Deep-learning/Life-long learning attitude
    ○
    Self-awareness/efficacy/reflection
  • Instructor’s
    ○
    Self-awareness
    ○
    Supervisory role
[2,4,5,6,18,39,47,48]
Facilitates
  • Becoming an independent learner
  • Becoming a life-long learner
  • Change in attitude/knowledge base/performance (i.e., competencies)
  • Developing strategies for the learner, allowing changes to occur
  • Development of the instructor due to self-reflection on their own clinical teaching practices, the so-called ‘transformative reflection’
[2,4,5,6,17,19,51]
Informs the learner on
  • Omissions
  • Preferred learning style
  • Progression in educational milestones
  • Strengths
  • Weaknesses
[5,6]
Reinforces
  • Deep learning
  • Good attitude/knowledge/performance
[2,5,6,33,39,47,48]
Table
Table 2. Types of feedback categories used in education and their basic description.
Table 2. Types of feedback categories used in education and their basic description.
Category of FeedbackType of FeedbackDescriptionReferences
ContentFormalTime required: 5–20 min. Usually provided around middle of the course/rotation, at least bi-monthly, or at the end of the activity. Provided following the guidelines for effective feedback.[6,18,38]
InformalUsually given during clinical encounters or the debriefing. More effective and influential.[4,6]
Duration of the sessionIn-depth
(Major)		Time required: 10–30 min. Usually scheduled and provided weekly, around middle of the course/rotation, at least bi-monthly, and/or at the end of the activity. Should be in a private setting. Suitable for individual learners only. NOTE: The amount of exchanged information may overwhelm the learner.[5,6,16,18,38]
Insignificant
(Brief) 1		Time required: <5 min. Usually unscheduled and discussion concentrates on everyday laboratory/clinical activities given in the context of the work. Should be given on-the-go or at least daily. Suitable for both individual learners and groups of learners[4,5,6,16,38]
Emotional aspect of the sessionConstructiveSpecific, Thoughtful, Actionable, Timely, Individualized, and Criterion-referenced (STATIC) and delivered in a nonevaluative, non-judgmental way. Assisting development of the learner; therefore, stimulating deep learning.[5,6,31,32,48]
DestructiveGeneral, subjective, and often judgmental assessment. Demotivating the learner; therefore, learner loses interest in deep learning.[5,6,48]
Quality of feedbackEffectiveSTATIC.[13,16,27]
IneffectiveDelayed, generalized, non-actionable, non-specific, and vague.[19,27]
MediocreAt least one of the elements of STATIC not provided effectively and/or vague.[27]
Sentiment of the sessionNegativeStating shortcomings/weaknesses and agreeing on strategies for improvements. Provision of negative feedback may be challenging.[5,6,13,48]
NeutralGeneralized, not stating strengths or weaknesses.[6]
PositiveReinforcing what has been done well/strengths.[5,6,48]
1 One strategy for ensuring timely feedback is to incorporate feedback into each clinical encounter (e.g., using the Five Microskills model [4].
Table
Table 3. Reasons for delivery of feedback as used in education.
Table 3. Reasons for delivery of feedback as used in education.
ParameterAppreciationCoachingEvaluation
DescriptionInforming the learner that their efforts are noticedHelping to improve, learn, grow, or change, either to correct an existing problem or immerse in new challengesCurrent performance, ranking against set of standards
Satisfies the need forBuilding relationshipCorrecting deficiencies, deep learning, facilitating development of learner–instructor relationship, learning guidance, mutual trust, reinforcing success, using failure as a catalyst for learningAlignment of expectations between learner and instructor, clarification of consequences, ensuring attainment of competencies, guiding decision making, level of competencies, and setting expectations
Recommended phrasing Nouns and verbsAdjectives and adverbs
Expression Constructive and non-judgmentalComparative and judgmental
Timing ContinuousEpisodic
Applicability to provision of effective feedbackNoneHighShould be avoided although not completely excluded
Table
Table 5. Models used in provision of feedback to veterinary medical learners.
Table 5. Models used in provision of feedback to veterinary medical learners.
ParameterFive Microskills ModelAsk-Tell-Ask ModelPendleton RulesSandwich Model
Application to clinical teachingWide 1Mid narrow 2 to wideMid narrow 2 to wideWide
CenteredLearner-centeredLearner-centeredLearner-centeredInstructor-centered
Description
  • Get a commitment
  • Probe for supportive evidence
  • Teach general rules
  • Reinforce what was done well
  • Correct mistakes
  • Ask the learner for self-assessment
  • Give the learner constructive feedback on their self-assessment
  • Ask the learner to summarize the discussion and prepare a plan for action
  • Learner self-reflects on positive attitude/knowledge/performance
  • Instructor gives accolades on the achievements
  • Learner self-reflects on negative attitude/knowledge/performance
  • Instructor acknowledges recognition and proposes corrective feedback for omissions and weaknesses
  • Delivery of a correctional feedback sandwiched between positive comments
Advantages
  • Brief (excluding training)
  • Develops goals
  • Easy to train the instructor and learner to use it
  • Identifies plan for action
  • Reinforces both corrective and positive feedback
  • Develops plan for action
  • Easy to train the instructor and learner to use it
  • Two-way discussion
  • Identifies goals and plan for action
  • Learner sets the agenda and instructor builds on it
  • Reinforces both corrective and positive feedback
  • Can be very brief
  • Good for an instructor new to providing feedback
  • Reinforces positives feedback
Disadvantages
  • Assumes learner can self-reflect
  • Need for learner and instructor training
  • The brief feedback element, not specifically labelled, may not be recognized as feedback by the learner and, most frequently, lacks formal recording
  • Assumes learner can self-assess
  • Requires time to prepare
  • Time consuming
  • Artificial separation of negative and positive attitude/knowledge/performance
  • Assumes learner can self-assess/reflect
  • Learner’s set agenda may prevent comprehensive coverage of feedback
  • May lack in reflection
  • Time consuming and increases likelihood of skipping the action plan
  • Lack of eliciting learner’s self-assessment/reflection
  • Learner usually concentrates on corrective feedback only
  • Positive feedback usually diluted by the effect of the corrective feedback
  • Usually addresses a single activity/event
1 Wide: applicable to a variety of clinical teaching modalities (e.g., clinical encounter, laboratory activity, and practical class); 2 Mid-narrow: mainly applicable to clinical encounters and/or course/rotation performance.
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Carr, A.N.; Kirkwood, R.N.; Petrovski, K.R. Use of Effective Feedback in Veterinary Clinical Teaching. Encyclopedia 2023, 3, 928-946. https://doi.org/10.3390/encyclopedia3030066

AMA Style

Carr AN, Kirkwood RN, Petrovski KR. Use of Effective Feedback in Veterinary Clinical Teaching. Encyclopedia. 2023; 3(3):928-946. https://doi.org/10.3390/encyclopedia3030066

Chicago/Turabian Style

Carr, Amanda Nichole (Mandi), Roy Neville Kirkwood, and Kiro Risto Petrovski. 2023. "Use of Effective Feedback in Veterinary Clinical Teaching" Encyclopedia 3, no. 3: 928-946. https://doi.org/10.3390/encyclopedia3030066

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