Principles of Constructive Feedback
Pendelton et al. (1984) realised that to learn about the consultation through analysis of videos of
consultations it was essential to provide a safe secure environment. Good feedback should
maximise learning opportunities, whilst minimising any difficulties. To ensure this they
developed some rules, which are known universally in medical educational establishments as
“Pendelton’s Rules.”
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Briefly clarify matters of fact.
Learner being observed comments on what was done well and how.
Rest of group then comments on what was done well and how.
Learner then comments on what could have been done differently and how.
Rest of group then comments on what could have been done differently and how.1
Reasons for these Rules
Discussing strengths first engenders a safer more supportive environment.
It is more helpful to be able to own a difficulty than to be criticised by another about something
without first having a chance to mention it.
Feedback should only be given when a suggestion for change can be provided, i.e. not just
what was wrong, but how it could have been managed differently.
Constructive feedback:
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Praising is easy
Criticising is even easier
Constructive feedback requires
1. Listening skills
2. Analytical skills
1. Listening skills
 Non-verbal behaviour: attention/eye-contact/positive feedback
 Focus comments on the experience to the speaker
 Accepting ideas and feelings & not dismissing explanations
 Empathy
 Probing ("you said that.." "tell me more about...")
 Summarising to check understanding
 Widen discussion by suggesting alternatives
2. Analytical skills
 Let the person in the hot seat speak first - often is realistic!
 Good points first
 Plan a solution to the problem
 Be sensitive to the person
 Show interest and involvement
 Be constructive
 Show that the problem exists
 Encourage suggestions of improvements
 One point at a time
 Criticise the act not the individual
1
“The Consultation.” Pendelton et al. (1984)
Giving Feedback
The process of review is important to us all - we can all learn from both our mistakes and our
successes. Successful review requires an ability to give and receive feedback honestly, clearly
and effectively.
 Feedback should always be positive and supportive.
 Feedback is non-judgemental, clear information to the other person.
 Your own thoughts, feelings and opinions by making 'I' statements (rather than 'you'
statements).
 You speak directly to the other person (rather than talking about them to others).
 You comment on the behaviour, not the person.
 You are specific in your comments.
 You may suggest constructive ways of improving behaviour/ performance.
Receiving Feedback
When you are receiving feedback from others, whether criticism or praise, do not let your
feelings get in the way of using the important information which is being offered.
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Listen actively without comment until the other person has finished speaking (avoid
interrupting with explanation or defence).
Accept compliments assertively - own Your strengths.
If the feedback is 'loaded' in some way, do not immediately rise to the defensive or
crumple in dismay. Express your feelings about the statement: 'I feel
angry/upset/confused when you say that'.
Ask for comment on your behaviour rather than your personality.
If the feedback is vague, ambiguous or generalised, ask the speaker to be more specific:
'What exactly was it about my behaviour in the situation which you liked/disliked?'
Ask the speaker how they would rather have you behave.
Do not swallow criticism whole; look for consistent feedback from a number of people before
you do. Take responsibility for which aspects of the feedback you will act on - it is your choice to
change your behaviour.
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Listen to the feedback rather than immediately rejecting it or arguing with it.
Be clear about what is being said.
Check it out with others rather than relying on only one source.
Ask for feedback you want but don't get.
Decide what you will do as a result of the feedback.
Examples: Descriptive rather than judgemental
e.g
“You started well, excellent”
This does little to say why something was good.
“At the start of the consultation you had good eye contact and were obviously listening
carefully to what she was saying”
This descriptive feedback specifically tells doctor what he has done well.
“The start was awful.”
This may lead to defensiveness in the doctor, a judgement has been made implying that the
observer is comparing the doctor to a set agreed standard against which he has failed.
“At the start of the consultation I noticed that you were looking down at the notes and the
position of your chairs prevented good eye contact between yourself and the patient.”
This is non-judgemental and although the comment is negative it is constructive.
 Specific rather than general
General, non specific, vague comments can be unhelpful, and may even antagonise the doctor.
“You didn’t empathise with her”
It is more helpful to focus on descriptions of actual behaviour.
“She seemed unhappy, it was difficult to tell from your facial expression and body
language whether you had taken that on board”
When giving feedback it is important to own your own thoughts, use first person singular: “I
think….” rather than “we think…” or “most people think…”
It is important to focus on your own viewpoint and this particular scenario rather than a
generalised situation.
 Focus on behaviour rather than personality.
Describing someone as a“loudmouth” comments on their personality, by saying “You seemed to
talk quite a lot, the patient tried to interrupt but seemed to have difficulty getting into the
conversation,” comments on their behaviour. Behaviour is easier to alter than personality: we
are more likely to change what we do than what we are
 Feedback should be for the learner’s benefit.
Feedback should not be an escape valve for the observer, patronizing superior comments tend
to give the observer a psychological advantage. Feedback should be tailored to help and
encourage the learner.
 Information should be shared rather than advice given.
Good feedback generates alternatives, makes suggestions and shares information. This
enables the learner to make appropriate choices for his next step.
 Give feedback only about something that can be changed
There is no point in reminding someone about a mannerism or other shortcoming that cannot be
altered.2
2
“Teaching and Learning Communication Skills in Medicine” Kurtz, Silverman & Draper (1998)
Principles of agenda-led outcome-based analysis
Start with the doctor's
agenda
Ask what problems the doctor experienced and what help he
would like from the rest of the group.
Always look at the
outcome you are trying
to achieve
Thinking about where you are aiming and how you might get
there encourages problem solving -effectiveness in
communication is always dependent on what you are trying to
achieve.
Always allow the doctor space to make suggestions before the
group shares its ideas.
Encourage selfassessment and self
problem-solving first
Involve the whole group
in problem solving
The group should work together to generate solutions not only
to help the doctor but also to help themselves in similar
situations.
Use descriptive feedback
to encourage a nonjudgmental approach
Descriptive feedback ensures that non-judgmental and specific
comments are made and prevents vague generalisation.
Provide balanced
feedback
Each group member should ensure that they provide a balance
in feedback of what worked well and what didn't work so well:
this supports the learner and maximises learning -we learn as
much by analysing why something works as why it doesn't.
Make offers and
suggestions, provide
alternatives
Make suggestions rather than prescriptive comments and
reflect them back to the doctor for consideration. Think in
terms of alternative approaches.
Rehearse suggestions
Rehearse and practise suggestions by role play -when learning
any skill, observation, feedback and rehearsal are required to
effect change
Be well intentioned,
valuing and supportive
It is the group's responsibility to be respectful and sensitive to
each other.
Value the interview as a
gift of raw material for
the group
The interview provides the raw material around which the
whole group can explore communication issues: group
members can learn as much as the doctor on the tape and
should be prepared to make and rehearse suggestions -the
doctor should not be the constant centre of attention.
Opportunistically
introduce concepts,
principles and wider
discussion
The facilitators should opportunistically offer to introduce
teaching exercises and research evidence to help to draw out
principles of communication and to illuminate learning for the
group as a whole.
Structure and summarise
learning so that a
constructive endpoint is
reached
The facilitators should summarise the session to ensure that
learners piece together the individual skills that have arisen into
an overall framework to structure and summarise the session.
Agenda-led outcome-based analysis in practice
Prior to showing the tape
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Ask the doctor showing the tape to set the scene, describing prior knowledge of the
patient and listing the extenuating circumstances! We should know exactly what the
doctor knew and was feeling when the patient entered the room and no more.
Instruct the group on noting down very specific words and actions plus their times as an
aid to descriptive feedback.
Ask one member of the group to watch as if the patient and be prepared to role play the
patient after wards to enable rehearsal
After showing the tape
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Allow the group several minutes to collect their thoughts and identify the one or two most
important points they would like to bring up in feedback, making sure to provide a
balance.
Facilitator to consider where to place feedback on what worked well.
Acknowledge any feelings of the doctor showing the tape if necessary
Start with the doctor on the tape
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What areas do you want to highlight as being problems for you? Tell us your agenda:
has it changed on reviewing? - write up agenda items.
What help would you like from the rest of the group?
What outcome would you like to achieve?
Facilitator to consider whether to add in own or group's agenda here.
Negotiate with the doctor the best way of looking at the tape -whether to replay and
which bit.
Get the doctor to start off looking at own agenda by showing again the relevant part of
the tape and asking to use descriptive feedback to say what worked well and what didn't
work so well.
Elicit thoughts and feelings of doctor and possibly patient if appropriate.
Rehearse with one of the group role playing the patient.
Encourage offers and suggestions from the rest of the group and further rehearsal
To the group as a whole
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Summarise where we have got to back to the group and ask for their help' prompt with
SET-GO feedback.
Rehearse all suggestions through role-play.
Add in facilitator's ideas and thoughts.
Appropriately introduce generalising away into teaching areas and exercises.
Clarify with doctor on tape that own agenda has been covered.
Ask group for any agenda of their own that we have not covered already.
Be very careful to balance what worked well and what didn't work so well by the end.
Ending
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Ask what everyone has learned (one thing to take away) and whether the feedback was
useful and felt acceptable.
Descriptive feedback
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Non-judgmental
Specific
Directed towards behaviour rather than personally
Checked with the recipient
Outcome based
Problem solving In the form of suggestions rather than prescriptive comments
The SET-GO method
Group members to base feedback on...
3. What I Saw
Descriptive, specific, non-judgemental. Facilitator to prompt if necessary with either or
both of...
4. What Else did you see?
What happened next in descriptive terms?
5. What do you Think, John?
Reflecting back to the doctor on he video, who is then given the opportunity to
acknowledge and problem solve.
Facilitator then to get the whole group to problem solve
3. Can we clarify what Goal we would like to achieve?
An outcome-based approach
4. Any Offers of how we should get there?
Suggestions and alternatives to be rehearsed if possible.
Source: Silverman, Draper and Kurtz: Education for General Practice vol 7 no 4 and vol 8 no 1.