“Sowing the seeds” the use of feedback in postgraduate medical education : a key factor in developing and enhancing clinical competence.

Abstract

Background: The importance of feedback in enhancing clinical competency in the postgraduate medical education arena is well documented. Many definitions of, and models and frameworks for delivering feedback exist. Trainee specialists must learn how to use the feedback that they receive to hone their knowledge, skills and professional performance. Clinical supervisors must be equally effective in delivering the best feedback possible in all spheres of the training platform so as to impact positively on performance. However, while many studies have explored how feedback is given and received in postgraduate medical education, these studies have been conducted in homogenous settings. Aim: This study set out to examine how contextual and demographic factors affect the provision of feedback in a clinical training environment with heterogeneous demographics. This study aimed to investigate the perceptions of the registrars, consultants and Clinical Training Heads regarding the quality and factors that influence the process of giving and receiving feedback, so as to make recommendations for improvement and to develop policy guidelines for the enhancement of postgraduate clinical speciality training in diverse clinical training environments. Methods: A mixed methods approach was adopted for this study. Qualitative and quantitative analysis was done regarding the perceptions of the quality of the current delivery of feedback across six disciplines at a teaching hospital. Consultants and registrars consented to complete a questionnaire consisting of open- and close-ended questions to determine the quality, quantity, type and timing of feedback. Responses were coded on a five-point Likert Scale and combined to give an overall positive or negative response. The relationship between demographic factors such as age, race, gender, home language and discipline of study were also evaluated, with responses to open-ended questions used to extend and enrich the quantitative data. Descriptive statistics were used to analyse the data. Differences between groups were calculated using Pearson’s Chi Square test for independent variables, with a p–value of < 0.05 regarded as being statistically significant. Semi-structured interviews were conducted with the Clinical Training Heads to explore their feedback regarding the feedback received about feedback from the consultants and registrars. The Walt and Gilson (1994) triangular framework for policy analysis was used to explore the perceptions of current practice of the Clinical Training Heads of six major disciplines. A thematic analysis was conducted of their perceptions of how feedback was currently given and received by consultants and registers, with a view to developing policy guidelines to improve the practise of giving and receiving feedback. Results: The results revealed a disparity in the perceptions of consultants and registrars regarding current practise. Although consultants believed that they provided adequate feedback, registrars disagreed, citing an overall dissatisfaction with the process. Registrars believed that consultants lacked training in how to give feedback , and that important elements such as prior provision of the standards to be obtained, as well as feedback being based on directly observed performance were missing. Consultants concurred that they lacked capacity in how to give adequate feedback, but felt that heavy workloads, fear of negative reactions and the apathy of registrars as well as their failure to act on feedback when given, hampered the process. Male consultants and registrars both reported better experiences of giving and receiving feedback overall. Registrars who were English second language speakers had statistically significantly more favourable outcomes with feedback compared to English first language speakers. The Clinical Training Heads reported that lack of appropriate institutional support and an overall guiding framework, combined with multiple administrative bodies of registrars as well as language barriers, were challenges to be overcome. They identified areas for future improvement, including standardisation of the process, more effective use of logbooks and better monitoring and evaluation. Conclusion: Registrars and consultants agreed that feedback was essential to ensuring that clinical competencies were achieved. However, ongoing in-service education and training of consultants and registrars was necessary to ensure that consultants were fully capacitated to provide constant, high quality feedback and that registrars were able to recognise feedback when it was given. Feedback needs to be an integral part of the culture of the university teaching and learning ethos. To this end, policy guidelines incorporating elements of identified ‘Best Practices’ on how to give feedback were developed and recommended for implementation under the auspices of an overarching Postgraduate Committee for Teaching and Learning.