Updated: 20 November, 2024

In healthcare education, implementing structured feedback models is crucial for developing effective communication skills among students, as healthcare professionals—nurses, doctors, and dentists—must convey complex medical information clearly to patients and collaborate with colleagues across various specializations. They also need to empathically share bad news when necessary. Despite the importance of these skills, they are often inadequately integrated into health science programs.

Feedback models, such as the Feedback Sandwich, Pendleton’s Rules, and the Multisource Feedback model, provide educators with frameworks to deliver constructive criticism and guidance effectively. These models ensure that feedback is specific and actionable rather than vague, helping students learn to give and receive constructive criticism in a safe environment. Practicing these skills prepares students for real-world interactions where effective communication is essential for patient care and teamwork.

This article outlines the pros and cons of several feedback models and provides a roadmap for the integration of feedback training and integration in undergraduate medical education. 

Feedback Models and Their Application in Undergraduate Medical Education

Various feedback models possess distinct strengths and challenges, making them more appropriate for specific contexts and greatly impacting how students receive and utilize constructive criticism. This section examines several key feedback models, emphasizing their applications and implications within clinical training environments.

The Feedback Sandwich

• The Feedback Sandwich model involves delivering critical feedback “sandwiched” between positive comments. This approach aims to cushion the impact of criticism by starting and ending with praise.
  • Process: The feedback provider (observer) begins by highlighting what the individual did well. – The observer then introduces specific areas that need improvement and focuses on behaviors rather than personal attributes. – The feedback provider concludes with additional positive feedback to reinforce their strengths and motivate them to improve. 
  • Pros: This model may protect the recipient’s self-esteem and make them more receptive to criticism.
  • Cons: It can dilute the significance of critical feedback and may be perceived as insincere.
  • Application: Introduction to Clinical Skills
    • Rationale: It is ideal for practical sessions where students perform clinical skills on peers or standardized patients. Peers can provide positive feedback on what was done well, followed by constructive criticism on areas needing improvement, and conclude with encouragement to reinforce confidence.

Pendleton’s Rules

• Pendleton’s Rules centers around the fact that feedback should be balanced, specific, timely and learner-centered. This model encourages recipients to reflect on their performance before receiving suggestions from the feedback provider.
  • Process: The feedback recipient (learner) states what went well. – The feedback provider (observer) states what went well. – The  learner states what could be improved. – The observer states what could be improved. – The learner summarizes and makes an action plan.
  • Pros: By prioritizing the recipient’s perspective, this model promotes self-reflection and ownership of learning.
  • Cons: The focus on initial responses may limit the provider’s ability to offer immediate guidance or correct misunderstandings.
  • Application: Internal Medicine, Emergency Medicine
    • Rationale: This model encourages students to first reflect on their performance before receiving feedback. This two-way dialogue fosters a deeper understanding of their strengths and echoes areas for improvement, promoting a reflective learning culture and self-awareness.

The ECO Model

• The ECO Model focuses on emotions, content and outcomes. It emphasizes eliciting an emotional response (E) before discussing content (C) to establish outcomes (O).
  • Process: The feedback provider (observer) provides feedback. – The feedback recipient (learner) expresses their feelings about the feedback they’ve received. – The observer acknowledges and validates their emotions and discusses the actual content of the feedback, clarifying any misunderstandings or ambiguities in the feedback. – The learner and the observer then develop an action plan based on the feedback and set specific goals for performance enhancement. 
  • Pros: Acknowledging emotions can enhance receptivity and create a safer environment for constructive dialogue.
  • Cons: However, focusing on emotions first could prolong the feedback process and distract from essential content.
  • Application: Patient Communication and Empathy Training (Palliative Care, Hospice, Geriatrics, Oncology)
    • Rationale: It emphasizes understanding emotional responses before discussing content, which is critical in healthcare settings where empathy plays a significant role.

Multi-source Feedback (MSF)

• Multi-source Feedback (MSF), also called the 360-Degree feedback model, gathers input from various sources, including peers, instructors, patients, and self-assessments.
  • Process: The feedback recipient (learner) collects feedback from multiple sources through surveys and completes a self assessment. – The feedback is compiled and analyzed by the feedback provider (observer) and a comprehensive report is generated including benchmarking against peers. –  The learner received the feedback report during a debriefing session. – Both parties develop an action plan based on the feedback and set specific goals for implementation.
  • Pros: MSF provides a comprehensive view of performance by capturing diverse perspectives 
  • that highlight strengths and weaknesses.
  • Cons: The process can be time-consuming and complex due to reconciling differing perspec
    tives and ensuring feedback validity.
  • Application: Clinical Rotation & Internships
    • Rationale: Feedback from diverse sources allows us to recognize our natural strengths in specific roles within team dynamics or areas of expertise. This understanding can guide undergraduate students in their decision-making process when selecting a specialization. For a more detailed explanation of this feedback model, check out this article.

Feedback Literacy Model

• Developed by Carless and Boud, the Feedback Literacy Model equips students with essential feedback skills. It helps students understand, utilize, and manage feedback effectively. The model encompasses four interrelated elements. First, it emphasizes appreciating the value of feedback. Second, students learn to make judgments about their own work. Third, it addresses managing emotional responses triggered by feedback. Finally, students are encouraged to take action based on the feedback received.
  • Process: The feedback provider (observer) must discuss with the feedback recipient (learner) the relationship between feedback and improvement, explaining the different forms of feedback and framing it as an ongoing process of discussions, questions and back-and-forth. – The observer should teach strategies for self assessment and peer assessment and provide opportunities for learners to connect these skills to future workplace scenarios. – The observer recognizes that emotional responses can be both barriers and motivators for improvement and support students in acknowledging and working with emotions related to feedback. – The feedback provider encourages the learner to actively engage with the feedback and provides opportunities and tasks that align with improvement goals.
  • Pros: This model promotes self-directed learning and improvement.
  • Cons: As a relatively new concept, it lacks extensive empirical validation and requires significant investment in training from the feedback provider.
  • Application: Clinical Rotations & Internships
    • Rationale: This model empowers students to actively engage with feedback processes, allowing them to respectfully and objectively disagree with feedback as well as collaborate with the reviewer in the development of an action plan to move forward with improvements.

The MISCA Model

• Described by Lipnevich et al., the MISCA model stands for message, implementation, students, context and agents. It emphasizes the dynamic interplay between feedback characteristics, student characteristics, and the objectives. This model proposes interactions both within and between elements.
  • Process: Define the feedback content and type. – Clarify the purpose of the feedback (i.e. improving patient care, enhancing clinical skills, department efficiency). – Assess individual characteristics of the feedback recipients (i.e. experience level, specialization, motivation, emotional responses, cognitive processing abilities). – Evaluate the healthcare setting, consider timing and mode of delivery (i.e. immediately after patient discharge, scheduled monthly reviews). – Identify feedback providers (i.e. senior physicians, peers, patients), encouraging multi-source feedback for a comprehensive view, and train them on effective feedback techniques in healthcare settings.
  • Pros: It offers a holistic understanding of feedback by putting the student at the center of the feedback process. 
  • Cons: Since it is not a sequential process, its complexity can make practical implementation challenging.
  • Application: Continued Education Programs for healthcare professionals (MD, RN, EMT, PA, etc.)
    • Rationale: Suitable for ongoing institutional training programs or workshops designed for healthcare professionals at various stages of their careers as it acknowledges the dynamic nature of feedback and encourages ongoing reflection, adaptation and collaboration amongst peers.

Practical Examples

Roadmap for Feedback Training and Integration

• Faculty Development: Conduct workshops for faculty to build a common language and understanding of key feedback principles. This can include exploring different feedback models, their benefits, and limitations in the context of medical education, such as the ECO Model, Pendleton’s Rules, and the Feedback Literacy Model.
  • Focus on Effective Feedback Practices: Emphasize the importance of providing specific, actionable, and timely feedback that is focused on observed behaviors, rather than personal traits. Highlight strategies for creating a safe and supportive learning environment where feedback is seen as a tool for growth.
  • Discuss Challenges and Strategies: Address potential challenges associated with giving and receiving feedback, including managing emotional responses, handling challenging feedback conversations, and mitigating biases. Share strategies for overcoming these challenges and promoting constructive feedback dialogues.
  • Explore Ethical Considerations: Discuss ethical considerations related to feedback, including confidentiality, fairness, and the potential impact of feedback on student well-being.
• Student Training: Conduct orientation sessions for students to introduce the concept of feedback literacy.
  • Define Feedback: Provide a clear definition of feedback, emphasizing its role in promoting learning and professional development.
  • Explain the Benefits of Feedback: Highlight how engaging with feedback can improve performance, enhance self-awareness, and support career growth.
  • Clarify Expectations: Articulate clear expectations and examples for giving and receiving feedback, outlining acceptable and unacceptable feedback behaviors.

Strategies for Enhancing Feedback Effectiveness

To maximize the impact of feedback in medical education, several strategies can be employed:

1. Providing Specific and Actionable Feedback: Focus on concrete observations rather than vague comments. Specificity helps guide student learning effectively.
2. Creating a Culture of Feedback: Establish an open environment where feedback is viewed as a valuable growth tool. This involves modeling constructive practices and promoting open communication between students and instructors.
3. Training Students on Feedback Skills: Explicitly teaching students how to give and receive effective feedback improves peer assessment quality and enhances overall feedback literacy.
4. Integrating Feedback into Collaborative Learning: Utilizing collaborative learning environments can provide authentic opportunities for peer feedback while promoting accountability among students.
5. Closing the Feedback Loop: Timely opportunities for students to act on feedback are crucial for improvement. Incorporating feedback into subsequent assignments or facilitating reflective discussions can help achieve this goal.

Structured feedback models in healthcare are crucial for developing effective communication skills among medical students and professionals. Healthcare professionals need to clearly explain complex medical information and collaborate with patients and colleagues on treatment plans. Many health science programs unfortunately neglect teaching these critical communication and collaborative skills.
Innovative feedback models create supportive learning environments, providing frameworks for constructive criticism and systematic performance improvement.

Online platforms like Videolab offer flexible integration of feedback models, enabling asynchronous debriefing sessions for healthcare education programs. Students and instructors can easily upload, share, and receive comprehensive performance feedback through the platform. Videolab’s robust privacy and commenting features help users concentrate solely on developing communication and clinical skills.