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HomemibusinessFeeding Back in a Clinical Environment

Feeding Back in a Clinical Environment

If you’ve ever been asked to mentor a recent graduate optometrist or a student in your practice, you’ll know that sharing expertise can be rewarding and enjoyable. However, it can also be a challenge. That’s because most optometrists have never been taught how to teach or supervise others. So what are the tips for success?

A key component of successful supervision is providing constructive feedback to your learner. The strategies below will help you feel more confident about mentoring students and/or junior optometrists.

KOLB’S THEORY OF LEARNING

There’s no doubt that students and junior optometrists learn while examining patients. Direct patient care helps identify areas in which they might be struggling and where clinical decisions could be improved. When student optometrists see patients in clinical environments, we have a valuable opportunity to measure their ability, and assist them, to transition from simulations to real world situations.

In a clinical environment, the best learning comes if the individual takes time to make sense of their experience

In 1984, David Kolb published his Experiential Learning Cycle,1 which highlights the central role that ‘doing a task’ plays in the learning process.

Kolb’s theory suggests that the steps in learning are:

Concrete experience: doing a task,

Reflective observation: reviewing what has been done and experienced,

Abstract conceptualisation: making sense of what happened, and

Active experimentation: reflecting on how what has been learnt can be put into practice.

Kolb emphasises however, that most learning happens afterwards, as a result of reflecting on the experience. In a clinical environment, the best learning comes if the individual takes time to make sense of their experience. This reflection is strongly enhanced if feedback is provided by an experienced observer who actively watches the task. This is where you come in.

SETTING UP THE CLINICAL ENCOUNTER

To start the process of feedback, you and your student need to decide on the task you are going to provide feedback on. You should also decide how and when it will occur – ideally, you will agree to a conversation at the end of the clinical session.

Watching a complete eye examination is very time consuming and often not productive. Instead, plan to focus on part of the examination – such as taking a history or performing a refraction. Giving your student the option to determine which aspect of the consultation they might like feedback on will engage them more fully and is particularly appropriate if you are working with newly graduated optometrists. During this discussion, gauge how well you expect them to complete the task, based on how many opportunities the student has had to do it previously, and any other relevant experiences they might have had.

At this stage, it is important for you and your student to decide how each of you will interact with the patient involved in the session. Prior to the consultation commencing, it is also important to make sure the patient is comfortable to be involved in the process.

WATCHING THE TASK

To provide effective feedback, you will need to be an active observer from the moment the student commences their task.

As you observe, think about these questions:

  • What are you seeing and what would you be doing if you were performing the task… Are they performing to the expected standard?
  • Where is the student at in their training and what skills or knowledge do you expect them to have at that level… are they demonstrating the expected skills or knowledge?
  • Are there aspects which don’t look right in what you are observing and why?
  • What do you see that could be improved?
  • How is the patient reacting and are they being considered appropriately in the interaction?
  • What is the student doing well?
  • If you could change one thing at this time, what would it be?

Take notes as you watch to ensure you don’t forget your observations. The most effective feedback is delivered as a few key points – you may choose not to discuss all that you have observed.

THE FEEDBACK CONVERSATION

Feedback is usually best delivered as soon as possible following the activity. Ideally, allow a break of five to 10 minutes for the student to collect their thoughts and for you to decide on key points.

Research shows that feedback is also most effective when delivered in conversation, as opposed to a monologue. There are many suggested models for you to follow when giving feedback, but one that I use is the AERO model. In this model you ask your student questions, which help turn the feedback into a conversation in which you both participate.

AERO

A. Affective question that considers the learner’s emotional response to their performance; eg. “How did you feel about that?” 

E. Effective question that asks what the learner thinks they did to contribute to a good patient outcome; eg. “What did you do that worked well?” 

R. Reflective question that prompts the learner to review their own performance; eg. “What might you do differently next time?” 

O. Objective question that allows you to provide your views on the student’s performance; eg. “Would you like to hear my views?” 

Case Study: AERO in Action 

Your student has expressed interest in performing some refractions on older patients. A 70 year old patient comes in for an appointment and is happy for the student to be involved in the consultation. He is no longer satisfied with his multifocals that were prescribed at your practice two years ago.

You sit and actively watch your student do the refraction on your patient. They start from the previous patient’s prescription. They successfully determine the best vision sphere in the right eye, but then take over five minutes to determine that the right eye has a -0.25 cylinder at axis 90. You notice a similar pattern when the left eye is refracted. The best vision sphere is found well, but the astigmatism amount is small and the student takes a long time to complete the determination. The student then proceeds to binocular balance the patient. This is done efficiently using an appropriate technique. The final answer is exactly what you find when you check the result yourself.

A. You ask your student how they felt about their performance and they respond that they are pleased that they got the same answer as you did. 

E. You check what they felt worked well, and they articulate that they did the best vision sphere components well. 

R. You ask what they might do differently next time, and they self-identify that doing a binocular balance on a 70 year old was not necessary, and that they had forgotten to think about this particular patient’s context. 

O. You offer your views and confirm that their refractive finding was accurate. You then remind the student about the effect on vision of a -0.25 cylinder at 90, and the time they spent to determine that. You talk about the context of the importance of this cylinder finding in the overall examination of the patient and other tests to be done. You show them how you determine a small cylinder prescription and talk through the steps for finding this efficiently. 

EFFECTIVE FEEDBACK

When providing feedback, students prefer supervisors who are knowledgeable, caring and professional. They want to be provided with specific actions they can take away that will help them improve their performance – constructive feedback is far more helpful than simply being told “this is wrong”. Additionally, feedback is most effective when it provides the optimum balance between challenge and support for the learner. And finally, the opportunity to use the feedback to enhance their work is important, so allowing the student to do the same task soon after will be ideal.

FEEDBACK ON FEEDBACK

Learners like to learn in different ways, and supervisors have different styles when providing feedback. This means that providing feedback the same way to all students won’t work, so you will need to adapt your feedback style. Watching the way your students react to your feedback and reflecting using AERO on your own strategies and skills is useful. Asking your students about your feedback and how they feel it could be improved will help you help them.

Anthea Cochrane is a Senior Lecturer with the Department of Optometry & Vision Sciences at the School of Health Sciences, The University of Melbourne.

References 

Kolb David A. Experiential Learning: experience as the source of learning and development. Englewood Cliffs, Prentice Hall, 1984