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77]

Commentary

The Criteria of Constructive Feedback: The Feedback that

Counts
Introduction about what has gone right as well as what has gone wrong,
there is feedback that we define as constructive feedback’.[11]
In the field of education, feedback is described as information
The features of constructive feedback depicted here is that
regarding the students’ performance that is provided with
feedback should highlight and strengthen good performance,
the intention to improve their learning. [1] The positive
delineate poor performance, provide remedial action plans and
impact of feedback on learning stems from a large number
involve two parties; preferably working as an ally.[11] Other
of research studies in the medical education literature.[2]
criteria of constructive feedback include that it should be:
In the educational enterprise, feedback enhances learning,
Timely, specific, supportive, relevant, informative, accurate
promotes acquisition of skills and drives professional growth
and understandable.[12] Constructive feedback has several
and development.[3,4] However, some evidence are currently
advantages that are proposed to enhance learning in educational
showing that feedback can sometimes be ‘done badly’
settings. It motivates learners and inspires and promotes them
resulting in unwanted consequences and leading to the failure
for learning.[13] It can be used as a tool for high‑quality learning
of producing its expected outcomes.[4‑6] Altmiller reported an
and to stimulate growth and professional development of
increased frequency of uncivil behaviour in nursing education,
learners. It has also a positive influence on the professional
which is attributed to lapses and gaps in the provision of
development of feedback providers as well.[11]
constructive feedback. This escalating pattern of incivility is
linked to some bad teachers’ behaviours in the execution of This article reviews and summarises some of the literature
feedback, which instead of being constructive may harm the regarding feedback with the intention to identify the criteria
teacher‑student relationship and fuel retaliation by the students of constructive feedback; the feedback that is desired and
as a response to the uncivil behaviour.[7] It was identified that expected to improve students’ learning and performance.
it is easy for teachers to provide their students with positive
reinforcing feedback, but it is difficult to provide them with Methods
constructive feedback (positive criticism).[7] This difficulty has
A short review of some of the published literature on feedback
been referred to teachers’ fear of insulting their relationship
in the context of medical education was conducted aiming
with their students, and sometimes due to their anticipation of
to identify the essential features of constructive feedback in
poor evaluation by their learners when poor performance is
terms of its criteria as well as its recommended and beneficial
criticised.[8] Poor feedback often results in a ‘dismissive and
practices. These will be discussed under two sections; general
defensive reaction’ which means, at a glance, the learners
and conceptual characteristics, and criteria related to the
would not accept the feedback and they would not work on
quality of the feedback. The article hopes to shed light on the
it. However, on the long‑term, this could also have some
most important criteria of constructive feedback, however,
evident consequences such as reduced motivation and limited
the list of criteria described in Table 1 is not meant to be
engagement with future feedback.[9]
comprehensive.
• Weak feedback has poor, and probably sometimes
negative, impact on learning
• Providing constructive criticism on performance is a Table 1: Features of constructive feedback
challenging task but could be learnt General Feedback message
• Constructive feedback motivates learners, improves their Use of dialogue Immediate
learning and enhances their professional growth . Effective communication Specific
Explicit criteria of performance Helpful
A conducive learning environment Accurate
The Arena of Constructive Feedback Enabling curricular and teaching designs Relevant
Tailored
Providing the students with constructive criticism regarding Solicited
their performance is crucial to reinforce their learning;[10] Frequent
however, it is found to be a challenging task.[8] The proposed Balanced
characteristics of constructive feedback appear in some Confidential
of the definitions of the term. Hamid and Mahmood in Understandable
their review of constructive feedback have recruited the Non‑judgemental
following definition ‘Where there are agreed standards of Based on first‑hand data
behaviour and performance, and two‑way communication Involves corrective plans

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Omer and Abdularhim: Constructive Feedback

Conceptual Characteristics of Constructive • Specific: Addresses certain points of performance and not
be based on generalisations.[5] Thus, feedback information
Feedback such as, ‘your physical examination skills of the patient’s
• A collaborative learning environment: That is nourished abdomen needs some revision’, is rarely helpful to the
by confidence, trust and respect and admires the value student who performed the task because he will not
of teamwork. A student‑learner relationship nurtured by know which part of his/her performance particularly
mutual trust and confidence will create a safe environment, requires attention. Instead, it would be more useful to
in which learners can learn more effectively from their the student if you said, ‘the way in which you put your
supervisors in clinical settings[14] hand on the abdomen for superficial palpation requires
• Use of dialogue: To enhance the active role of improvement, your wrist should be straight? Try to kneel
students in the process of feedback and strengthen down’ explaining why his/her performance is not correct
their self‑regulation capacity.[15] This coincides with the and suggesting a method for correction; feedback should
operational definition of feedback concluded by van de concentrate on behaviours that can be changed. Learners
Ridder et al., in his comprehensive review of feedback found feedback most effective when it focuses on specific
definitions in the context of medical education. They performance, especially when it is accompanied by
viewed feedback as a cycle that includes information reasons of why performance was inadequate[22]
and reaction. They added that feedback could be referred • Non‑judgemental: Phrased in non‑evaluative language,
to as a process of communication.[1] The ability to which could hamper the defensive attitude of some
self‑evaluate and self‑regulate is an essential attribute of students;[6] for example, information such as, ‘your history
accomplished practitioners and it provides them with the of the patient’s illness did not cover the possibilities of
capacity to learn for life, even beyond formal educational pancreatitis and peptic ulcer disease’, non‑judgemental
programmes. Novice learners, on the other hand and due sentence, is much better than when you say, ‘your history
to lack of expertise, are in particular need to instil these was so deficient’, judgemental sentence
skills in them to produce imperative feedback results[13] • Based on first‑hand data: Provided by the same person
• Curricular and teaching designs: That foster engagement who attended the event so that the learners are likely to
and provide multiple feedback opportunities.[16] Modern believe in it.[14] Altmiller asserted that speaking in the first
medical curricula should embed feedback as a key person using I instead of he/she would enhance a teacher
component of their structure. Learners should be actively credibility and shows the information provided as factual[7]
involved in teaching activities and should be given • Accurate: Based on real observation and assessment
opportunities to observe their performance whenever of performance;[5] it should report events as they have
possible. Attention to the importance of practicing occurred and avoid bias.[7] Kuvaas et al., have indicated
self‑ and peer assessment exercises, and encouragement that when feedback is not seen as accurate and acceptable,
of the habit of reflection are essential and should remain it would generate disagreement between the feedback
on top of the mind of programmes’ leaders and course provider and receiver, and in that occasion, it is less likely
instructors[17] to be taken and acted upon to improve performance.[23]
• Effective communication: Early sharing of goals, expected Ruscher et al., have pointed that feedback that is overly
outcomes and standards of quality performance.[18‑20] positive may be viewed by learners as a kind of pity
Van den Bergh et al., highlighted the importance of the and sympathy that could result in the feedback being
goal‑directedness nature of feedback. They asserted the disregarded[24]
need to develop explicit and clear learning goals and • Suggest plans for improvement: Not limited to one
communicated them to the students. The effectiveness of situation and advises actions for future improvement.[15,25]
feedback here is that it should be related directly to the A key feature of constructive feedback that is commonly
learning goals to yield a good outcome.[21] According to mentioned is that it provides options for improvement in
Ramani and Krackov, (2012) when instructional leaders future tasks, which increases its effectiveness and allows
and learners jointly develop and share the learning goals the students to view it as an opportunity for learning[7,23]
of a course or rotation, both of them can test and adjust • Seen as ‘helpful’: Not embarrassing, respectful, focuses
their performance in relation to the achievement of those on behaviour not personality and balances positive and
goals at any stage of the learning experience.[10] negative comments. In this way, it is less likely to elicit
negative emotional reaction in learners.[26,27] Beginning
Specific Criteria Related to the Quality of with caring statements is a useful strategy that reflects
teachers’ motivation and his/her concern about his/her
Feedback learners and allows the students to feel safe during the
• Immediate: Presented while the event is still fresh in the process; an example is, ‘I am saying this because my
student’s mind.[14] This also entails feedback to be provided ambition is to see you an excellent doctor in the future’.
with the person who attended the encounter, which further Beginning with caring statements encourages the
increases its credibility[8] students to accept and work on the feedback and should

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Omer and Abdularhim: Constructive Feedback

be assembled in every feedback message.[7] Moreover, • Confidential: Provided without intermediary and privately
Murdoch‑Eaton in 2012 has indicated that negative in suitable situations.[34] Provision of feedback, particularly
feedback tends to generate responses of avoidance, that one which highlights underperformance, to learners in
prevention and obligation that would likely jeopardise front of patients and their peers may embarrass the learner
the role of feedback in learning[13] and limit the usefulness of the feedback.[5]
• Solicited rather than imposed: Benefit from formal
and informal occasions to arise and endorse the active Tips for provision of constructive feedback
role of students in seeking information regarding • Establish a safe learning environment enriched with trust
their performance. [17,28] Fong et  al., mentioned that and respect
feedback‑seeking attitudes are encouraged in learning • Develop and share clear learning goals
environments in which ‘informational feedback’  ‑  the • Embed self‑  and peer‑assessment exercises in teaching
feedback that involves information on goal progress activities
and how to accomplish it ‑ is provided.[29] Delva et al., • Observe students’ performance and provide feedback
pointed to the interplay of other factors in shaping the whenever possible
feedback‑seeking habit of learners. They recommended • Acknowledge good performance and suggest plans to
the establishment of a learning climate that encourages correct mistakes
feedback and building comfortable relationship between • Ensure understanding of the feedback and check its
teachers and learners to foster feedback‑seeking application in future tasks.
behaviour[30]
• Relevant: Targets specific learning performance tailored
to the individual needs and interests of learners. [14] Conclusion
Ibrahim et al., elaborated on interns’ dissatisfaction with Constructive feedback is an essential adjunct of effective
performance appraisal in his study and reasoned that to learning. Application of constructive feedback on the ground
the lack of perceived relevance of many of the appraisal requires some enabling factors, which involve a safe learning
domains. He recommended the involvement of immediate environment, effective communication, clear learning goals
supervisors, who work with interns on a daily basis in the and suitable curricular and pedagogic strategies. In addition,
delivery of performance feedback and more emphasis on the feedback message should be immediate, specific, accurate,
personal feedback addressing one’s own strengths and confidential, relevant, tailored, understandable, voiced in
weaknesses.[9] Hauer and Kogan have asserted the need non‑judgemental language and provides suggestions for
to address provision of feedback in areas in which the improvement. Such feedback could be assigned as an effective
students are most interested, for example, their bedside feedback that would likely enhance students’ learning.
clinical skills, rather than commenting on their written Provision of constructive feedback is a skill and competency
assignments and verbal presentations[14] that can be learnt, thus faculty development programmes
• Balanced: Amount of information delivered is neither and deliberate practice of high‑quality feedback is strongly
scanty nor overwhelming.[28,31] Ramani and Krackov encouraged.[9,13]
have advocated that the amount of feedback presented
in an encounter should be limited to what the learner can Ahmad AbdulAzeem Abdullah Omer, Mohhamed Elnibras Abdularhim
absorb[10] Department of Surgery, Faculty of Medicine, University of Tabuk,
Tabuk, Saudi Arabia
• Understandable: So that learners can act upon it, and
the feedback loop could be closed.[15,17] Feedback that Address for correspondence: Dr. Ahmad AbdulAzeem Abdullah Omer,
is not understood and not followed by advice on how P.O. Box 3718, Tabuk 71481, Saudi Arabia.
performance can be improved is unlikely to enhance E‑mail: [email protected]
learning[23]
• Of multiple cycles: Provided sequentially over extended References
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