Future Research in Feedback: How to Use Feedback and Coaching Conversations in a Way That Supports Development of the Individual as a Self-Directed Learner and Resilient Professional

Research in feedback in medical education has increased exponentially over recent years. As we consider it, we may forget that Ende over 35 years ago identified the basic principles of effective feedback: be objective and specific, engage the learner, build trust, invite the learner’s views.1 We are still striving to put these principles into practice as learners continue to report that they are not receiving helpful feedback and faculty admit reluctance to provide corrective feedback.2 Yet, there is also much progress: Researchers have debunked the notion that feedback is a unidirectional delivery process and now view it as a dynamic 2-way conversation undertaken within a respectful, engaged relationship, the goal being to promote growth through facilitating feedback acceptance and use and offering appropriate challenge.2,3 We also know that diverse factors, both external in the medical education environment and internal within the individual, influence decisions to accept and use feedback. In particular, feedback discordant with one’s own perceptions of performance is often less readily accepted and used.4 Further, humanistic approaches—that is, those that engage the individual and focus on personal goals and development—can facilitate its acceptance and use. Included among these are coaching strategies and use of action and follow-up plans, all of which can also foster engagement and collaboration between feedback provider and recipient.5–7 Feedback, then, can be a powerful teaching strategy for fostering learners’ continued development and growth. More broadly, medical education serves to prepare learners for their complex roles as physicians, including the capacity to be self-directed yet function capably as team members, to make decisions on their own yet know when to ask for help, and to maintain their own health and sense of well-being in the presence of multiple system and other demands.8 Reports of alarming levels of stress and burnout among learners and physicians direct our attention to ways of preparing learners for these complicated roles and nurturing their resilience.9,10 A recent study identified lack of timely, meaningful feedback as a central contributing factor to depression among residents.11 Studies such as these expand our awareness of the influence of feedback and broaden the scope of pertinent research questions such as “How can we engage learners in feedback conversations in a way that supports their continued development as self-directed learners and resilient professionals?” To seek an answer, viewing feedback through a humanistic perspective which focuses our attention on self-actualization and continued development of the individual, guides us to theories that can contribute to our understanding of the role feedback plays in promoting growth. One such theory is self-determination theory, a theory of personal motivation and development proposing that humans have a natural tendency toward autonomous regulation of behavior and are intrinsically motivated to learn and take on challenges.12,13 To do so requires meeting 3 basic psychological needs: a sense of competence, autonomy, and relatedness. Of note, it is generally failure to meet these 3 needs that leads to burnout and diminishes resilience.10 Our question for medical education research then narrows and becomes “How can we engage learners in feedback conversations which foster their appropriate sense of competence, autonomy, and relatedness?” The following sections describe each of these psychological needs and, from recent research, suggest feedback strategies to foster each. Competence refers to “the desire to feel effective in whatever actions one pursues and performs.”12,13 Engaging learners in feedback conversations that appropriately foster their sense of competence, when the feedback suggests ways to improve and especially when it is discordant with their self-perceptions of their performance, can be complicated.2 Knowing that unguided self-assessment and self-monitoring are generally flawed,4,14 the challenge is to present data for improvement without threatening learners’ self-esteem and in a manner that will facilitate insight, acceptance, and use. Research shows that effective feedback strategies include building trusting, respectful relationships; sharing observations of performance without judgment; asking open questions to elicit learners’ views of their performance and those observations; facilitating reflection upon their performance and feedback; using coaching skills to facilitate goal setting; and developing action plans. A related challenge is to appropriately promote ongoing development when learners are doing well. Strategies to consider are seeking the learner’s views, goals, and aspirations and appropriately challenging them to develop an action plan. Autonomy refers to “the desire to be one’s own origin or source of behavior.”12,13 Contrary to popular belief, it does not mean acting entirely on one’s own. It means having a sense of free will in one’s actions, which carries with it the responsibility to recognize when to ask for help or seek external resources. Autonomy, competence, and insight go hand-in-hand in relation to one’s professional performance and knowledge and to feedback. Hence, tensions and sensitivities exist in feedback conversations intended to help individuals gain insight and recognize the boundaries of their competence while also supporting their autonomy, self-direction, and need for continued development. Providing a safe environment for them to admit they need to improve or need help and engaging them in a coaching conversation to guide their goal identification and action plan development can be effective strategies for supporting autonomy. Relatedness refers to “the desire to feel connected with others … to having a sense of belongingness, both with significant individuals as well as with a significant community.”12,13 It is not just being a member of that community but also knowing that one is accepted and valued by it and significant others. In the busyness of demanding clinical settings and frequent rotations, addressing the need for learners to feel related in meaningful ways to their preceptor and team members is often overlooked15; learners can feel lonely and isolated.16 Recent research demonstrates that effective feedback is grounded in an effective learning relationship, an alliance, between preceptor and learner.3,17 Preceptors can play a critical role in feedback conversations in creating that sense of connectedness for learners, for example, by taking a sincere interest in their progress, opportunities for improvement, goals, and action plans; letting them know that they are “there for them”; and connecting them to others who can help. Further, research on physicians in practice identifies that social isolation is not just a “relatedness” issue but is a risk factor for diminished competence. In summary, seen through the lens of self-determination theory, our research question has become “How can we use feedback to foster an appropriate sense of competence, autonomy, and relatedness within our learners?” The overarching question is broader: “Will such approaches also increase their development as self-directed learners and resilient professionals?” Given the breadth of these questions, considering specific subquestions that will begin to take us along the path to answering the broader ones is helpful. Several of these include the following: How can we support faculty in developing the specialized communication skill set required to conduct feedback and coaching conversations that promote the development of learners’ sense of competence, autonomy, and relatedness? Given the competing pressures to maintain competence in multiple domains, how can we help faculty make this learning a priority? How might we study the impact of such feedback and coaching conversations upon learners’ senses of competence, autonomy, and relatedness? What might be appropriate research outcome measures? How might we begin to study the potential contribution of development of each of these capacities, to the enhancement of appropriate self-direction and resilience? How might we effect change in our clinical learning cultures and environments to enable explicit support for feedback and coaching conversations that promote appropriate competence, autonomy, and relatedness? How might we also provide performance data to practicing physicians and engage them in similar feedback and coaching conversations? We now have an opportunity to empirically examine these questions and their underpinning conceptual frameworks, with the expectation that such work will contribute to the evolving definition of feedback and further understanding of its potential as a teaching approach.

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