Duckworth on Education: The 6 Rs of Feedback

To improve cardiac resuscitation outcomes, the American Heart Association’s resuscitation education science recommendations include the use of feedback in healthcare education programs. While the AHA makes these recommendations pertaining primarily to individual classes focused on individual resuscitation skills, the same tools can be used effectively to improve quality and enhance performance in a variety of circumstances. These include low- and high-fidelity medical simulation, real and simulated patient encounters, and even real-world emergency calls answered by experienced clinicians.

One framework that can help you provide more effective feedback in the learning environment involves six key steps. These are the “6 Rs” of effective instructional feedback: 

Ready—Students must feel set up for success before they will listen to any observations you’ve made about their performance. That’s not to say learning can’t occur if students are a little anxious. However, if students feel they’ve been set up for failure, then for them any feedback you give will be invalid. The parameters of the situation (rules of engagement) must be clear in their minds, as must any specific performance standards they’re expected to meet. There should be no mystery when students walk into a clinical situation or simulation about how the feedback will be provided. 

Realistic—If you want students to be ready to accept and act on your feedback, they must believe the situation they’re in and conditions they’re working under are realistic. This does not mean every teaching scenario must take place in a multimillion-dollar high-fidelity sim lab. It means that, with rare exceptions, the only thing students take away from contrived “torture tests” with unrealistically high expectations is that their instructors are sadists. 

It’s true that students can learn a lot from working in difficult or unusual situations, but first the students must accept that these situations are the kinds of situations for which they must prepare. When you provide your feedback, students left thinking, Yes, but this would never actually happen! or But this is definitely not my job! will not only not accept your feedback, they may completely disengage from the learning experience. 

Record—For feedback to be effective, the learners must first review the situation on which they’re being given the feedback. This requires two things, the first of which is recorded data. As much data as possible should be collected about the situation for which the students are receiving feedback. This can be via video recordings, transcriptions, written documentation, and basically anything that can objectively document who did what when, how much, and how well. The more objective data that can be collected, the more specific and actionable the feedback can be. 

Numerous studies have shown how poorly our perceptions and memories of even recent events reflect what actually happened. Recording objective data allows students the opportunity to learn from outside their own perspectives and begin to understand that perhaps there’s a need for learning they didn’t previously comprehend. 

Review—The second factor is the opportunity for everyone to review the key points from that data. Perhaps the situation was a brief patient simulation that permits review of an entire video recording. In situations where there is too much or not enough data collected, highlight key points.

Time is precious for every educator and student. There is often pressure to reduce or eliminate time allocated for review under the false assumption that “everyone was there, everyone knows what happened.” Giving in to this temptation shortcuts the learning process by allowing the incorrect perception that because we didn’t see it on review (because we never looked), the poor performance either didn’t occur or had no consequences.

Reflect—This is more than just allowing students time to think about what they’ve done. This is where most of the behavior change and performance improvement occurs. The reflection step allows the educator to shine as the “guide on the side,” facilitating reflection and directing the conversation. A variety of debriefing and performance improvement tools can provide a framework for educators to help students change behaviors where necessary and, more important, build on their successes. An effective reflection step is flexible, guided by the students, and allows the educator to explore important teaching points that support the learning objectives.

Rules—In this step educators help students focus specifically on the information, strategies, and actions that will result in real-world improvements in patient outcomes. The word rules is not used to mean strict rules a student must follow to avoid punishment. Here rules is used as in rules of engagement to help guide students’ clinical decision-making as they encounter new, challenging, and dynamically changing patient care situations. If need be, help clarify not only what these points are but how students may achieve them in their next patient encounter. 

The first two steps help prepare the student to accept and utilize the feedback you will provide. The next two help students think past their own perceptions to better connect their performance with patient outcomes. The final steps help students change mistakes and build on achievements to make significant differences in real-world patient outcomes.

Rommie L. Duckworth, LP, is a dedicated emergency responder and award-winning educator with more than 25 years working in career and volunteer fire departments, hospital healthcare systems, and public and private emergency medical services. He is currently a career fire captain and paramedic EMS coordinator.