Educator Feedback Skill Assessment: An Educational Survey Design Study

Abstract

Background: Delivering impactful feedback is a skill that is difficult to measure. To date there is no generalizable assessment instrument which measures the quality of medical education feedback. The purpose of the present study was to create an instrument for measuring educator feedback skills. Methods: Building on pilot work, we refined an assessment instrument and addressed content and construct validity using expert validation (qualitative and quantitative). This was followed by cognitive interviews of faculty from several clinical departments, which were transcribed and analyzed using ATLAS.ti qualitative software. A research team revised and improved the assessment instrument. Results: Expert validation and cognitive interviews resulted in the Educator Feedback Skills Assessment, a scale with 10 items and three response options for each. Conclusions: Building on the contemporary medical education literature and empiric pilot work, we created and refined an assessment instrument for measuring educator feedback skills. We also started the argument on validity and addressed content validity.

1. Introduction

1.1. Conceptual Framework

The ultimate goal of assessment practices in professional health education is improved healthcare. High-quality and credible feedback is necessary to provide a meaningful mechanism through which physicians can be expected to grow [1]. Feedback is fundamental for everything we do—it is an essential part of every framework, every curriculum, and every teaching interaction.

Despite the importance of feedback, residents and faculty thought that provider feedback skills were not sufficiently developed [2,3]. Similarly, faculty from both university and community-based programs described having minimal training and a lack of understanding of the best practices for delivering feedback [4], despite the availability of excellent practical guides [5,6,7]. It does not appear that this is a perception issue—a qualitative study of simulated feedback encounters suggested that faculty skills do not match recommended practice in a number of areas [8].

There is growing evidence that utilizing teacher-centered models of feedback is not sufficient to improving the quality of feedback [9,10,11,12,13,14]. Characteristics of feedback providers form one of the three clusters seen when viewing feedback through the lens of the sociocultural model [15]. For example, improving feedback provider skills may in fact improve outcomes. Sargeant and other colleagues have shown that training coaches to conduct a reflective feedback conversation can improve the acceptance and uptake of feedback [16]. Similarly, supportive coaching has been associated with both perceived coach competence and satisfaction in the sports realm [17].

1.2. Related Research

In order to explore the intended meaning and breadth of the feedback construct, we completed the following steps in a pilot study [18]. We started by conducting a literature review that aligned the feedback construct with prior research and identified existing feedback scales. We then explored how feedback participants conceptualize and describe feedback. We asked feedback recipients (resident physicians) to select, script, and enact six faculty-resident feedback vignettes.

We then conducted seven faculty focus groups that included 23 feedback providers. We asked the faculty, who watched each vignette video as a group, to comment on elements that were successful and on areas for improvement. Synthesizing the literature review and focus group findings ensured that our conceptualization of the feedback construct made theoretical sense to scholars in the field and used language that feedback providers understood. It allowed us to draft a list of 51 items that we grouped under 10 proposed dimensions of feedback and to create an early assessment scale, initially named Feedback Rating Scale (Appendix A 

Table A1. Pilot Feedback Rating Scale (FP = Feedback-Provider, FR = Feedback-Recipient).

Feedback Dimension	Feedback Items
Preparation, Engagement, Investment	FP dedicated adequate time to the feedback conversation
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP was honest about not enough time or not enough facts
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP ensured quiet, private, appropriate environment
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP minimized disruptions
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP was prepared, present, engaged and paying attention
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP was making eye contact and leaning forward
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP was not ‘just going through the motions’
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP was organized and completed the encounter
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Defining Expectations	FP defined expectations for performance
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Encouraging Self-Assessment	FP encouraged the FR to self-assess
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Beneficence, Encouragement, Respect	FP was warm, approachable, supportive, encouraging, & reassuring
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP was positive and used positive language
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP was polite and respectful
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP was constructive without offending
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Exploration, Reaction, Dialogue	FP listened
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP facilitated a dialogue
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP reacted to FR self-assessment and other comments
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP probed deeper and asked for elaboration
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Using Facts and Observations	Feedback was based on observed performance by FR
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Specificity, Use of Examples	FP described specific examples of specific FR behaviors
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Confidence, Direction, Correction	FP remained calm, composed, and non-confrontational
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP redirected and disarmed
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP confronted wrong resident perceptions
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	FP confronted inappropriate FR behaviors
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Individualizing Conversation	FP adapted the feedback conversation and their approach based on FR comments and behaviors during the feedback encounter
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
Next Steps	Feedback conversation included specific areas for improvement
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	Feedback conversation included measurable goals
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	Feedback conversation included realistic action plan
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
	Feedback conversation included discussion of a timely follow-up
	Strongly Disagree	Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree

).

Although several feedback delivery frameworks have been described, these are applicable to narrow areas within medical education. Several assessments were developed within specific contexts—written feedback [19], simulation debriefing [20], direct observation of clinical skills [21], communication skills feedback [22], feedback by residents [23], and feedback assessed by medical students [24,25]—however, these instruments are not generalizable to other types of feedback. The major research gap in this domain is therefore the absence of a reliable measurement instrument that can be applied to multiple facets of medical education.

The purpose of the present study was to (a) define dimensions that best represent the construct of feedback in medical education, and to (b) create and refine a generalizable assessment instrument for measuring educator feedback skills.

2. Materials and Methods

2.1. Research Model

This is an educational survey design study. We adopted Messick’s construct validity framework [26]. We selected Messick’s framework because, in contrast to the earlier validity frameworks that focused on “types” of validity (e.g., content or criterion), this approach favors a unified framework in which construct validity (the only type) is supported by evidence derived from multiple sources [27]. We envisioned our study findings being one of such sources that begin the “validity argument”.

For additional guidance in the study design, we selected a systematic and practical approach for creating high-quality survey scales that synthesized multiple survey design techniques into a cohesive mixed-methods process [28]. Building on our pilot work, we addressed the content, construct, and response process aspects of validity.

2.2. Participants

• To explore the content aspect of construct validity using expert validation, we recruited an international panel of methodologists, researchers, and subject-matter experts.
• To conduct cognitive interviews, we recruited experienced feedback providers from 4 clinical departments (Emergency Medicine, Medicine, Orthopedic Surgery, Physical Medicine and Rehabilitation) at a single academic health system.

2.3. Data Collection Tools

1.

The experts were asked to comment on each item’s representativeness, clarity, relevance and distribution using an anonymous online form:

https://docs.google.com/forms/d/e/1FAIpQLSffLngxbC_XTBv31dQDi0ftczjz3wDMGrfz_ZcOmLimcnPXiA/viewform (accessed on 5 December 2022).

2.

Experts rated each item as essential, useful but not essential, or not necessary using an anonymous online form:

https://docs.google.com/forms/d/e/1FAIpQLSfD83pEZhq_z-KRhDLFNM3bJCtxfRopCFAIRAb_TTs1D96J0g/viewform?usp=sf_link (accessed on 5 December 2022).

2.4. Data Collection Process

To assess how clear and relevant the items are with respect to the construct of interest, international experts were asked to comment on each item’s representativeness, clarity, relevance, and distribution using an anonymous online form. We also asked the experts to review the labels used for the response categories (qualitative review: content aspect of construct validity using expert validation). We asked the same group of experts to review individual items in the modified assessment instrument. Experts rated each item as essential, useful but not essential, or not necessary using an anonymous online form (quantitative review: content aspect of construct validity using expert validation).

To ensure that the respondents interpreted items as we intended (response process validity) we asked experienced feedback providers to use the assessment instrument, modified in above steps, and to rate videotaped feedback encounters that we developed as part of the pilot study [18]. We then conducted structured individual cognitive interviews utilizing the technique of concurrent probing [29]. This technique involves the interviewer asking about the respondent’s thought process while they are completing the questionnaire, and allows a reasonable balance between the demand on the respondent and minimizing the recall bias [28].

2.5. Data Analysis

Using the data collected during the qualitative reviews, we used expert responses and comments to modify and revise the assessment instrument. During quantitative expert reviews, we used both a predetermined content validity ratio cut-point (McKenzie recommends 0.62 minimum for statistical significance of <0.05 for a 10-member panel), and the narrative comments by experts to make inclusion and exclusion decisions for individual items [30].

Audio files of recorded cognitive interviews were transcribed, coded, and analyzed qualitatively using the ATLAS.ti software (Scientific Software Development GmbH 2019) in order to modify and improve the overall assessment instrument and the individual survey items. The research team used a consensus method in deciding on whether to proceed with each revision suggested by interviewees; suggestions that received at least three out of four research team votes were implemented.

3. Results

The majority of interviews were conducted face to face, however, the last two interviews were done virtually due to the COVID-19 pandemic-related restrictions. The assessment instrument (final version, Appendix A 

Table A2. Educator Feedback Skills Assessment.

Items	Rating			Comments
Educator appeared engaged	Distracted	Inconsistently engaged	Consistently engaged
Educator was prepared for the feedback session	Unprepared for the feedback session; did not know Learner or his/her performance	Prepared for the feedback session; knew some things about Learner and his/her performance	Prepared for the feedback session; knew Learner and his/her performance in detail
Self-assessment encouraged and incorporated in conversation	Self-assessment neither encouraged nor incorporated in conversation	Self-assessment encouraged OR incorporated in conversation	Self-assessment encouraged AND incorporated in conversation
Educator was respectful	Disrespectful	Inconsistently respectful	Consistently respectful
Educator was constructive	Not constructive	Inconsistently constructive	Consistently constructive
Educator facilitated dialogue	Did not ask questions, did not allow time for or dismissed Learner comments	Asked some questions, reacted to Learner comments	Asked many questions, allowed time for responses, encouraged Learner comments
Educator probed deeper and asked for elaboration	Did not ask for clarification or elaboration	Inconsistently asked for clarification or elaboration	Consistently asked for clarification or elaboration
Educator provided specific examples to Learner	Educator provided no examples	Educator provided at least one specific example	Educator provided many specific examples
Conversation included specific areas for improvement (WHAT to improve)	Conversation did not include areas for improvement	Conversation included at least one area for improvement	Conversation included many areas for improvement
Conversation included an action plan (HOW to improve)	Action plan was not discussed	Action plan was discussed in general terms	A specific action plan was discussed
GENERAL COMMENTS/ADVICE Please include any suggestions for this Educator

) was revised eight times during the research study (

Table 1. Tabulated Results.

Expert Qualitative Reviews	Experts Recruited	12
	Expert Comments	10
	Item Number Changes	Increased by 1 (31 to 32)
Expert Quantitative Reviews	Experts Recruited	12
	Expert Votes	8
	Item Number Changes	Decreased by 22 (32 to 10)
Cognitive Interviews	Total Participants Recruited	12
	Participants in Emergency Medicine	4
	Participants in Physical Medicine	4
	Participants in Internal Medicine	3
	Participants in Orthopedic Surgery	1
	Total Recommendations	23
	Incorporated Recommendations (>75% Votes)	7
Instrument Revisions		8
Instrument Name Changes		1

). The instrument name was changed from Feedback Rating Scale to Educator Feedback Skill Assessment (EFSA).

Qualitative review. Twelve experts agreed to participate (see Acknowledgements section). Ten of the twelve submitted narrative comments online. In addition to individual item revisions, the number of items was increased from 31 to 32 (one item was split to avoid “double barreling”).

Quantitative review. Eight of the twelve experts submitted “inclusion/exclusion” votes online. Ten of the thirty-two items had the content validity ratios of > 0.62, and were included in the final version of the assessment instrument.

Cognitive interviews. Twelve cognitive interviews were conducted, ten face to face and two online via Zoom. Participants included four teaching faculty in Emergency Medicine, four in Physical Medicine and Rehabilitation, three in Internal Medicine, and one in Orthopedic Surgery. Qualitative analysis of the interview transcripts yielded twenty-three recommendations. Seven of the suggestions received at least three out of four research team votes and were implemented in the final version of EFSA. To arrive at the final version of the assessment instrument (Appendix A Table A2), the PI made several additional changes to improve readability, reduce wordiness, and improve item format consistency.

4. Discussion

We believe a rigorous instrument that builds on existing theory and empirical evidence is necessary to measure the quality of feedback in medical education. Our study takes the first step in creating and validating such an instrument. Our results may also impact assessment in medical education in several ways.

Firstly, our findings may deepen the theoretical understanding of the dimensions of feedback necessary for making it meaningful and impactful, with the potential benefit for both medical education researchers and practitioners. Secondly, defining performance expectations for feedback providers in the form of a practical rubric can enhance reliable scoring of feedback performance assessments. Finally, although rubrics may not facilitate valid judgment of feedback assessments per se, they have the potential of promoting learning and improving the instruction of feedback providers by making expectations and criteria explicit, thereby facilitating feedback and self-assessment [31].

Our work started from de novo observations of feedback in a pilot project. While our findings were undoubtedly colored by the work of others and existing frameworks for feedback, we expect to further validate current methods of assessment, and explore and define novel dimensions of delivering feedback. Our work also built on an emerging area of feedback research supported by recent work of others and by our pilot work: specificity. Roze des Ordons and other colleagues identified variability in feedback recipients (4 ‘resident challenges’) and suggested adjusting feedback provider approaches accordingly [8]. Our own pilot [18], on the other hand, was based on scenarios that were selected, scripted, and enacted by learners (resident physicians), and the resultant data suggested additional variability in feedback providers. Using more than one perspective in developing items and dimensions of the assessment instrument may allow us to highlight multiple facets of the feedback construct and understand it more fully.

We think that the collaborative nature of this study is also a strength. Several prominent scholars with unique knowledge in assessment and feedback agreed to participate in expert validation (see Acknowledgements section). Within our own institution, we included faculty from 4 diverse departments in the cognitive interviewing, from both “cognitive” and “procedural” specialties, which supports the generalizability of the resultant instrument.

We addressed only one (content) of the four aspects (structural, content, generalizability, and substantive) of validity described by Messick [26], and this is undoubtedly the greatest weakness of this work. However, we feel strongly that once our new instrument is available to the medical education research community, the sooner this shortcoming can be addressed, by ourselves and by others. Additionally, early use of the instrument by the medical educators in the field is likely to provide feedback that will allow us to further refine and polish EFSA. Future studies will need to explore multiple facets of the feedback construct, while varying the types of feedback providers and feedback recipients. Another area of interest involves the study of different relationship stages, for example, one-time feedback vs ongoing coaching, ‘on the fly’ vs scheduled at the end of a clinical rotation.

To continue collecting the validity evidence, future studies should delve into the psychometric properties of EFSA focusing on structural aspects, as well as convergent and discriminant validity (external aspect). Future studies should also explore the relationship between EFSA and additional external measures such as motivation to use feedback, feedback-seeking frequency, and satisfaction with feedback using existing survey items [32]. The change in physicians’ behavior and performance and how they affect patient outcomes are also areas of future interest. Additional studies across different specialty areas and demographic variables should also be conducted to further explore the generalizability aspect of construct validity.

5. Conclusions

Building on the contemporary medical education literature and empiric pilot work, we created and refined an assessment instrument for measuring educator feedback skills. We also started the argument on validity and addressed content validity. Future studies should address structural, generalizability, and substantive aspects of validity, and test the new instrument in a variety of settings and contexts.