Pendleton Plus

Facilitating analytical feedback and reflection

A year ago I wrote about the debate surrounding Pendleton’s Rules for feedback and gave my view on why a structured approach is important.

A year down the line and I have amended Pendleton to reflect the good use I see it put to on a regular basis. My changes to the original address the concerns raised when critics of Pendleton discuss the framework:

Criticisms of Pendleton’s Rules:

* Pendleton's Rules often lead to narration of events: "I introduced myself, I introduced the topic, I asked a question...." (The 'what') and can omit to consider the analysis and application (the 'why' and the 'how') of the episode and the implications for future practice;
* Pendleton's Rules can leave learners unsure as to the quality of their teaching episode - was it good, poor, catastrophic - due to the 'balanced' feedback. Candidates want to (and need to) know how well they did.
* People struggle to give constructive feedback, or if they do, they either say what was sub optimal or how it can be improved, but not always both of those things.

I have heard from those who had used a less structured approach to feedback, that whilst this can be done extremely well, is not done well by up to 50% of the learner group.  (anecdotal, not evidence based using RCT!)

The challenge is how to introduce analysis and evaluation in a simple, structured format that even the most reluctant facilitator of feedback can confidently tackle.

The product of extensive discussions and some pre piloting is presented here – ‘Pendleton Plus’ retains the principles of Pendleton's Rules (the learner self evaluates first; positives are usually discussed first) but has a couple of slight changes:

Pendleton Plus:

1. Insight: Coach Ask: “How do you think that went?” (to find out the level of insight of the learner)

Headline: Coach Tell: “I thought that was excellent | very good | good| OK | slightly problematic | problematic – let’s go back through what you did and look at each part, as this can be improved”

2. What went well: Coach Ask: “Let’s look at what you think went well?” Add “why” and “how did you do that?” questions where relevant to promote analysis
3. What to improve: Coach Ask:  “Let’s look at what you want to improve or develop.” Add “why” and “how would you do that?” questions where relevant to promote analysis
4. Action Plan: Coach Ask:  “What will you do to take this forward?”

Step 1 is to briefly ascertain the insight of the learner and a simple headline evaluation from the facilitator:
So the facilitators asks the learner in one word to sum up how they felt they did. It is important here not to let them delve head first into regurgitating the narrative of their episode, or to metaphorically beat themselves around the head in anguish. This is a quick stock check, to enable them to give a gut feeling, and for you to add your gut feeling, before the real analysis starts.

Step 2 asks the Pendleton initial question or 'what did you think worked well?' But the difference here is that where often the facilitator would previously listen to the retelling of the teaching story, then provide their own (often second) teaching story, this time the facilitator prompts the learner with 'why?' and 'how' questions - 'why did that question bring them to life like that?' 'How did you move them onto that point?' In this way Pendleton steps 1 and 2 (learner positives, trainer positives) should be covered in one stage, with the facilitator questioning, prompting and if necessary making observations to develop learner understanding of what went well, why and how they achieved that.

Step 3 does the same but with the areas for development. Again, analysis should be encouraged through the use of questions and observations: 'why do you think they fell silent at that point?’  'I noticed you looked uncomfortable then - why do you think that was?' Development for future would extend this conversation using 'how' questions: 'how would you deal with a silence like that in future?' 'How would you avoid...?'

Step 4 ought to be a quick resume of follow up actions from the learner of 1-2 points they did well and 1-2 points they intend to address.

Having piloted this I was surprised to see the ease with which people picked it up. The benefit of the familiarity with the original Pendleton clearly helped, as did the clear structure. I was concerned with the possibility that this would take longer to do than the previous system but this was not the case at all. In fact, many feedback sessions were a little briefer as they cut out the time consuming narration. As long as the group understood the principles involved, they seemed to have no trouble at all.

A useful paper I am sure you will all recognise which supports the principles of Pendleton Plus and may be useful to have on hand if anyone asks for further information is  Cantillon P, Sargeant J: Giving Feedback in Clinical Settings BMJ 2008;337:a1961 doi:10.1136/bmj.a1961

Do let me know of your experiences in using Pendleton Plus.