Serving up Constructive Feedback – How to avoid those Inauthentic Sandwiches

Giving effective feedback is a core skill for medical professionals and the ability to do it well is a hallmark of a good teacher and colleague.  

But let’s face it – giving negative feedback can be hard, and we’ve all felt anxious in anticipation of those conversations. All of us can easily pull to mind several, often painful, examples of situations where we’ve either given or received poor quality feedback. But why is this? 

Well, part of the reason might be that, although it’s an essential part of working in large teams, supervising and developing junior colleagues, and continuing our own professional development, the majority of healthcare professionals giving feedback on a day-to-day basis don’t actually feel confident with the delivery of constructive feedback¹. As a result, our colleagues and trainees may be being underserved in the feedback experience we deliver to them.  

When it’s done badly, feedback is recognised to be damaging to confidence, and fails to redirect behaviours which may be deleterious to patient safety and workplace efficiency².  

However, when feedback is done well, it is a powerful tool – it’s well established in literature that effective feedback improves performance, adaptability and learning, helps us understand our strengths and weaknesses, and positively affects patient safety and care³.  

There is also a definite desire for feedback amongst colleagues – even if it that feedback is perceived as negative (or redirecting). In some literature, as many as 90 percent of workplace employees agree that redirecting feedback, if delivered appropriately, can be effective at improving performance⁴.  

As a result of the above, as healthcare professionals there is a need for us to develop our skillset in the delivery of authentic, meaningful feedback which allows our colleagues to develop and patient safety and care to be positively affected.  

What do we mean by “Feedback”?  

Feedback can be broadly described as “A description of performance in a given activity or task that is intended to guide future performance in a similar or related activity”⁵. 

Feedback can be either reinforcing (positive), in that it encourages the repetition of positive behaviours, or redirecting (negative), in that it encourages reflection and change of behaviours, skills or attitudes in similar situations in the future.  

There are a number of different sources of feedback for healthcare professionals – verbal, written, patient complaints, patient outcomes. The integration of several different sources of feedback generally is thought to add credibility to the feedback that is being given, whether that is reinforcing or redirecting.  

What about models of feedback for giving negative feedback – do you think they are useful ?  

There are a number of different feedback models that have been developed and are advocated to help provide structure to healthcare professionals in giving constructive feedback to colleagues. These are all slightly different, and have their own relative proposed drawbacks and criticisms.  I’m not a big fan of them and I’m going to try to explain why.  

Firstly, it’s important to recognise that there is no established best method of giving negative feedback. Consensus opinion and qualitative analyses of recorded episodes of feedback suggest that feedback is most effective and meaningful when it is an authentic two-way conversation between the giver and receiver of feedback, where self-assessment and reflective practice are integrated with shared educational goals⁶.  

As a result, when models of feedback are used, although they provide structure to the process, they have a tendency to feel very rigid and inauthentic when applied, and tend to stifle the two way communication, and self directed reflection and learning which is well recognised to shape educational development.  

As an illustration to this point, we’ll look briefly at perhaps the most well known of the feedback models – the so called “Sandwich” model ⁷.  

The Sandwich model consists of three main components :  

1. Begin with positive feedback  
2. Follow this up with negative or redirecting feedback (which is what you’ve wanted to say all along) 
3. Close with another piece of positive feedback  

The aim of the sandwich model is to minimise the detrimental effect of negative feedback on the learner and to avoid the learner becoming discouraged.  

For me, this model of feedback has a number of key criticisms and is fatally flawed as a feedback model. Sandwiching negative feedback between two pieces of positive feedback doesn’t soften the blow. It only creates confusion for those receiving the feedback, undermines the positive things you have said about them and decreases the trust between those giving the feedback and those receiving it. Although it might not feel comfortable to do, I would argue that being transparent about your reasoning for the corrective feedback sets the foundation for a more authentic, meaningful feedback experience.  

So, other than feedback models, how might we best approach giving negative feedback to a colleague?  

Firstly, we should start by trying to stop fearing having to give constructive feedback to colleagues. The literature clearly suggests a want for this type of feedback in the workplace. Giving feedback which, as a result, changes the behaviours, attitudes or skills of a team is a very powerful and rewarding experience. It has the ability to grow and develop team members, and to improve trust, communication and bonds between key members of the team, alongside positively affecting patient care.  

If we approach our colleagues in a sensitive, supportive way, anticipating a two-way collaborative discussion and aiming to set shared goals for progress then the process suddenly seems considerably less daunting.  

Prior to writing this blog post, I discussed the challenges of delivering constructive feedback with some colleagues who have themselves delivered some very powerful redirective feedback to me over the past few years, which has influenced the kind of doctor I am and the care I deliver to my patients.  Together, we agreed that rather than a model of feedback, there are instead some very useful overarching principles which can be applied to make the process as impactful as possible for all involved. 

An empathetic approach is key  

Receiving negative feedback that exposes a deficiency in performance can elicit very strong emotion for all involved. We can all bring to mind times where the sting of discovering a gap in our knowledge and skills caused us to feel upset or frustrated. Initially these strong reponses can be interpreted as defensiveness. As those giving feedback, we need to be prepared to give our colleague space and to place ourselves in their shoes, demonstrating empathy and providing support to them throughout the discussion.  

Keep feedback private and always deliver it face-to-face where possible.  

Wherever possible, try to deliver all significant pieces of feedback, both positive and negative, in a private but neutral environment. This ensures our colleagues feel respected and fosters a workplace culture where colleagues do not fear being publicly criticised. Delivery of face to face feedback allows for a personal connection and avoids misinterpretation of tone that can occur via email or other forms of feedback.  

Be direct and specific about concerns and give examples 

You should start the feedback by detailing concerns in a way that is clear, specific and, wherever possible, backed up with objective evidence, and that allows the person receiving feedback a clear way of making a plan to improve their performance. General comments which lack specificity like “Your documentation isn’t very good” leave the receiver of feedback in the dark with no idea of how to improve their performance. Instead, that feedback could be made clear and specific, and backed up by evidence by saying something like “I have noticed that family discussions have been occurring without documenting the contents of your discussion.  Last week the family of patient X asked for clarification of some points of your discussion but I could not find documentation of the original discussion to ascertain what had been discussed”. Being clear and specific, and backing up with objective examples allows the person receiving the feedback to clearly understand the parts of their behaviour that need to change and to make a clear plan to implement this.  

Focus on behaviours, not personality  

In giving redirective feedback, focus on describing the behaviours of a colleague, rather than focusing on their personality traits. Personality traits and characters in adults are relatively fixed, and criticism of character is generally not conducive to changes in practice, whereas behaviours can me modified. For example, rather an saying “You lack assertiveness”, you should say something like “ I noticed that you allowed a junior member to interrupt you and talk over you during the safety brief for that rapid sequence induction”  

Make the conversation a shared discussion 

Feedback is most effective when it is delivered as part of a two-way collaborative process in which you come to an agreeable consensus and set shared goals for improvement. Be prepared to allow the receiver of feedback to discuss concerns and allow them time to ask questions. Agree shared goals and set a collaborative timetable for further meetings and follow up.  

Follow up and praise progress 

Giving and receiving negative feedback is challenging, and it takes a lot of effort and energy to do it in a sensitive and impactful way. These conversations should not be treated as isolated conversations, rather as a process of continuous reflection and evaluation. When you see your colleague making progress, show appreciation for their efforts and reinforce them with positive feedback. This demonstrates that you care about their ongoing success and will help positively reinforce good practice.  

Take home message 

Giving constructive feedback to colleagues is a necessary part of growth and development, and of promoting a collaborative culture where quality is maintained and patient care is optimised. Rather than confirming to stiff, inflexible models of feedback delivery, we would advocate the use of authentic, empathetic and meaningful discussion utilising the the principles set out above.  

References  

1. McIlwrick, J., Nair, B. and Montgomery, G. (2006). ‘How am I doing?’: many problems but few solutions related to feedback delivery in undergraduate psychiatry education. Academic Psychiatry, 30(2), 130-135. 
2. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ 2008;337:a1961. 10.1136/bmj.a1961 19001006 
3. Crommelinck M, Anseel F. Understanding and encouraging feedback-seeking behaviour: a literature review. Med Educ 2013;47:232-41. 10.1111/medu.12075 23398009 
4.  Harvard Business Review. 2021. Your Employees Want the Negative Feedback You Hate to Give. [online] Available at: <https://hbr.org/2014/01/your-employees-want-the-negative-feedback-you-h…; [Accessed 10 March 2021]. 
5. Ramaprasad A (1983) On the definition of feedback. Behav Sci 28:4-13 
6. Hewson MG, Little ML. Giving feedback in medical education: verification of recommended techniques. J Gen Intern Med 1998;13:111-6. 10.1046/j.1525-1497.1998.00027.x 9502371 
7. Daniels, A. C. (2009). Oops! 13 management practices that waste time and money (and what to do instead). Atlanta, GA: Performance Management Publications.