Getting those end-of-term reviews can feel like a roller coaster you don’t want to be on. 🎢 Yet, a long list of research shows the importance of utilizing feedback to improve performance.  But those comments often feel yucky.  Why is that?  

Ineffective Feedback in Nursing Education

The feelings that come up with any review of our work are because reviewers often engage in two types of ineffective performance critiques.  

  1. Negative feedback ➖- We highlight what is wrong and what needs to be fixed.  The feedback provider feels efficient, but the feedback recipient is on the defensive.  
  2. Conciliatory feedback 🏆- We are vaguely positive and avoid giving direct criticism. This technique does not provide the recipient with any action items and feels insincere.  

What makes “good” feedback

Simply put, effective feedback leaves you feeling inspired to improve.  I’ll give you a quick example here of clear, actionable feedback.  In this case, you have just observed your graduate student Carla who is teaching a fluid and electrolyte lecture for the first time.  Here are characteristics of effective feedback:

🥅 Have a clear goal

  • One goal for the lecture was for students to understand hypo/hyper/isotonic fluids.  Provide comments directly related to this goal. For example, how did the activities connect to this topic?  Was their information that connected these fluids to clinical practice?

🏃🏽‍♀️Actionable

  • Be specific on which activities Carla should do more or less.  “Good job” is vague and not enough to improve.  Effective, specific, actionable feedback could be, “you need more instruction before this activity because the students seemed confused and took a few minutes to start.”

💪🏽User-Friendly

  • More is not always better. Give Carla two or three tasks to improve. Provide the suggestions at a beginner level. Great feedback does not overwhelm the recipient but instead gives them a few items that will yield immediate results.  

🕜Timely

  • Try not to wait days or weeks after the lecture to complete the feedback session.  Also, don’t give feedback during the lecture.  But the closer together the performance and feedback are, the better.  Immediately following the lecture would be the ideal time.

🚅Ongoing

  • Once the feedback is provided, Carla should get the opportunity to present a lecture again.  This powerful feedback loop allows learners to reshape their performance and make changes.

📈Focus on the process

  • Never criticize the person. For example, telling Carla the lecture was too long and boring will feel like a personal attack.  Instead, offer a process suggestion such as “why don’t you give only one example per slide rather than two or three.”  

A structure will help provide effective feedback

The Feedback Ladder was developed by David Perkins (2003). It was part of a project to create tools to help educators and learners give clear, fair, and balanced assessments of performance between positives and negatives. 

Where to use the Feedback Ladder in Nursing Education

The Feedback Ladder is applicable throughout nursing education in verbal presentations, written care plans, teaching projects, or observations in simulation. In addition, educators can use it to evaluate students, or students can utilize it in peer-to-peer evaluations.  

The tool can be used individually, in pairs, in small groups, or as a whole class.

If you are using this tool with peer-to-peer feedback in nursing education, you may want to discuss the importance of feedback to learning.  Explaining that the presenter is learning, just as they are, is a way for the students to empathize with the human they are evaluating.

You can download a copy of this worksheet here:

Blank Worksheet

Worksheet with Prompts

Case Study using the Feedback Ladder

In this example, we will continue the scenario where you give feedback to your graduate student Carla following her first lecture.

First, Carla shares her presentation with the classroom.  

Next, present the ladder—a few options of this.  If you are comfortable with the tool, you could casually start the steps without visual aid.  You could write down notes on the worksheet provided as Carla presents.  Also, you could show a graphic on a large screen for Carla to see as you discuss.  

🔎Clarify

Start your discussion with the clarify section by asking questions to understand Carla’s behind-the-scenes thinking further.  

  • Can you clarify why you chose to lecture first and then complete the activity?
  • Can you clarify the work you expected students to complete before class?

💎Values

Next, begin the values statements.  These statements draw attention to the presentation’s positive, thoughtful, and compelling aspects.  Using a value statement will help the presenter realize strengths in their work.

  • I appreciate how you did a warm-up activity at the beginning of class.
  • It was effective when you used a drawing to illustrate osmosis.

💭Questions

At this step, you start to raise questions.  Avoid judgemental statements such as “You should fix the delivery of that potassium section by practicing more.”  This approach can make the presenter feel defensive.  Instead, use questioning language to explore the situation.

  • From my perspective, it seemed like you were unsure about the nursing assessment section related to potassium.
  • What would happen if you had your notes available during your lecture on potassium?
  • You may want to look at KeithRN’s resource on potassium imbalance to improve your case study presentation.

💡Suggestions

This is where you provide concrete advice on how Carla could improve.  Here are some helpful phrases to use in the suggestion section:

  • What about adding . . .
  • You could consider reworking this part because . . .
  • A suggestion to make this section more effective would be . . .
  • It would be helpful to consider . . .

🎁Thank/Reflect

Thank Carla for sharing her expertise and receiving your feedback.   More importantly, allow Carla the opportunity to reflect. First, ask her to summarize what she is taking away from today’s lecture presentation. Then, encourage her to include at least one action step that she will take before her next lecture.

The process is the same if you ask students to evaluate their peers or give them structure for evaluating you as their instructor.  The role of presenter and responder just changes around.   

Alternative Uses in Nursing Education

As discussed earlier, the Feedback Ladder tool can be used between educators, nurses, peers, or supervisors.  Here are some ideas for using for feedback in nursing education:

  • Simulation observation – While 2-3 students enter the simulation suite to complete the scenario, the other students complete the ladder while observing.
  • Care plan evaluation – Before turning in a clinical care plan to their instructor, students review a peer’s care plan and attach the feedback ladder.
  • Presentations – If you have a presentation in class or clinical, have students submit the completed worksheet for 1-2 other students.  It will help keep the audience engaged with the presentation, especially if you do numerous back-to-back. Looking for ideas for classroom activities or presentations? Check out the Idea Bank for further active learning classroom topics!
  • Assessment observation – At clinical, have students observe a peer do a complete head-to-toe assessment on their patient and complete a feedback ladder.  When the assessment and documentation are complete, sit with the students to review the worksheet and their comments.
  • Skills lab – If you have hours to practice in the skills lab, have students observe each other and complete the feedback ladder as they watch another student.  
  • Theory note review – At the end of a class period, ask students to review a peer’s note-taking using the ladder.  They will practice critiquing a peer’s work and have the opportunity to see how other students do note-taking during class.

Conclusion

Learning to give effective feedback takes practice.  At first, students may need prompts and starter sentences for each section.  But as they become familiar with the tool, it will become more natural and ingrained in their communication.

As future nursing leaders, giving feedback is an essential skill, and we can allow students to practice in low-stakes settings as students. We can improve the process and structure for feedback in nursing education and find actionable items in those end-of-term reviews!

Did you know we have a community?

Head over to the ACTIVE LEARNING STRATEGIES FOR NURSE EDUCATORS Facebook group for more ideas and inspiration!

Martha Johnson is the charge nurse over at BreakoutRN

Martha Johnson MSN, RN, CEN

Charge nurse over at BreakoutRN with a focus on helping other nursing educators transition from lecture to active learning.  She believes it does not have to be hard or overwhelming, just take it one activity at a time 💜

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