Pendleton's rules

At the recent ATLS National Day and the Europen meeting of ATLS Educators there were discussions about other courses trying out different approaches to feedback. It seems as though Pendleton's rules for feedback http://www.gp-training.net/training/educational_theory/feedback/pendleton.htm are falling out of favour.

I was asked why this may be the case, and my personal view is that it is not the Pendleton framework which is at fault, but the struggle many people have to either understand the point of Pendleton, or to conduct a developmental conversation that is both specific, based on behavioural evidence and sufficiently constructive.

I have discussed various forms of feedback on here previously (see DEBRIEF), but wanted to make out a case for the use of Pendleton's rules.

For me the benefit of Pendleton is that it reaches all stages of learning, from the competent to the incompetent, and from that which we are aware of to that which we are not aware of.

As I have written before, learning is a matter of developing both competence and conscious awareness. We progress from a state of not knowing that we do not know or cannot do (unconscious incompetence) through the stage of being aware of what we do not know or cannot do (conscious incompetence) to one of knowing what we know and can do (conscious competence) to the final stage of knowing what we know and doing what we do but not being always aware of that (unconscious competence.)

If this is the case, and this learning curve describes the rudimentary stages we progress through when learning a new skill or behaviour, then feedback needs to access each of these stages of learning.

Pendleton's rules map onto these stages of learning beautifully:

1. Asking "What went well with that?" accesses the conscious competence quadrant and focuses the learner's mind on practice that needs to be repeated in future. This question also allows for the teacher to assess the levels of insight the learner displays, in their self evaluation.

2. Providing further discussion of what went well led by the teacher, develops the good practice and may access the areas of strength which the learner has no awareness of (unconsciously competent.)

3. Asking the learner what they were less pleased with and what could be developed further, also checks insight levels, and accesses the consciously incompetent areas of practice.

4. Finally, discussing with the learner what the teacher feels needs to be developed (with an action plan to do so) accesses the unconsciously incompetent quadrant.

Pendleton offers a framework within which we can discuss all aspects of the learning curve, including those areas of competence and incompetence known and unknown to the learner. What we need to do within each of the four questions advocated by Pendleton is to be specific about the strengths and areas for development, not shy away from being honest in our descriptions of the behaviours we have observed. And we must always encourage further actions which develop the weaker areas.

DEBRIEF: A reflective tool for workplace based learning

Hayley Allan

Why do we sometimes act inconsistently? Our heart is pulling us in one direction and our head is insisting on another. What about that gut feeling we have? You know that niggling feeling in the middle of the night? The knowledge, deep down somewhere that what we are doing is not totally right?

Survival has always depended on gut feeling. Humans would long be extinct if they did not have the ability to instinctively know when something is wrong. How many times do we hear someone saying that they “just knew” something was wrong? Paediatricians know that if the mother is worried, they ought to be worried. The girl who was mugged outside the internal front door of her second floor flat, knew there was something not quite right.  What is this sixth sense we all have and why are we advised to ignore it at our peril?

Call it intuition, call it experience. (It will depend on where you were schooled. If in the arts or social sciences you may favour intuition as a term for this phenomenon. Medics and those who deal with the allegedly more concrete world would call it experience. )

Experience is a tremendous learning tool because it develops in us over time; it steadily drip feeds our psyche while we work. Experience builds up pattern recognition over time. It swells the coffers of our intellect, adding to the vault of events and feelings that our mind stockpiles over the years. It is a rich resource. Many people, especially those who learned their craft through trial and error, through experimentation and throughput of events, believe there is no other way to learn.

But what if that accumulation of experience could be fast tracked? What if, instead of laying down lots of fifty pence pieces in the bank vault (individually heavy and of low value) we put by the (admittedly less frequent) stash of ten pound notes we came across? Is there a way to take more learning from fewer learning experiences?

Learning from experience and developing metacognition

DEBRIEF is a tool that enables reflection to take place between a number of people or individually. It provides a structure for review of an event in an emotional, a cognitive and a practical way, thus addressing the psychosocial and practical elements of learning. It has been acknowledged that learning is facilitated or hampered by emotions (Boekaerts 1993, Goleman 1995) and that emotions drive learning and memory (Sylvester 1994.) Learning is not a purely cognitive process (Le Doux (1997) Gross (2008) Love & Goodsell (1996). Much has been said about the emotional impact of learning. If we agree that learning is based on experiences then we cannot deny that emotions will play a part in those experiences and how we process them. The DEBRIEF model, in the constructivist tradition, helps learners to “take responsibility for their own learning, to be autonomous thinkers, to develop integrated understandings of concepts and to pose – and seek to answer- important questions.” Brooks & Brooks (1993)

Friere (1970) argued that learning and education is transformed through praxis – that is “reflection and action upon the world in order to transform it.” Vygotsky (1978 ) identified a zone of proximal development – a gap in terms of experience between two people at different levels of performance which could be used to “scaffold” (Wood et al 1976) the learning for the less experienced of the two. Scaffolding works best when functioning in a situated context or a Community of Practice (Lave & Wenger 1991) and remains the most practically useful way for many in training to learn. DEBRIEF offers a simple structure for such scaffolding to follow, but can also develop in time into internal DEBRIEFing, or metacognition.

Where are the trainers? And how do I know what I don’t know?

In current workplaces, trainees rarely have a supervisor with them all the time; the luxury of a more expert person always being at the elbow of the novice to question and support them in their thinking and practice is but a dream. If medical training is to be ‘trainee driven’ ( ISCP 2010, RCPath 2011,RCP 2011 ) then learners have to recognise their own learning needs and seek out an expert with whom to discuss those needs. However many needs, or gaps in knowledge and uncertainty about practice, fall into the zone of ‘unconscious incompetence.’ How can we know what we do not know if we do not know it and do not know that we do not know it? Once we are consciously competent (that is we know what we don’t know) there is not a problem, but often this conscious awareness has to be raised by either experience or a supervisor. If the supervisors aren’t there, we return to the learning by mistakes method, which is no longer tenable in the twenty first century.

This is where gut feeling comes in.


Fig 1. The role of conscious awareness in the development of competence.

There is a halfway house between unconscious incompetence and conscious incompetence where gut feeling resides. It is a small space, barely perceptible to some, but it can be developed given practice and the right conditions. Gut feeling can alert the learner to an inconsistency, or a ‘perturbation’ (Piaget 1954, 1971) and it is then the role of the learner to pursue this. There are several ways to do this, and usually the educational response is to seek out a supervisor or mentor for a conversation such as a Case Based Discussion, or to reflect on the perturbation independently. Both approaches can have limited effect. A CBD may yield a sophisticated level of analysis, resulting in new levels of understanding for trainee and even for the trainer. Often however, the conversation becomes didactic and theoretical and the synthesis between knowledge and application can be lost. Independent reflection is a good habit to develop but if the gut feeling is not explored purposefully and systematically there will be no real development beyond the ever decreasing circles we can be trapped in when trying to work out ‘what went wrong.’

DEBRIEFing

Debriefing is a mixture of reflecting and teaching. Using a framework to discuss the gut feeling with a more experienced colleague can lead to unexpected revelations. Once the framework has been practised several times it can work without another person’s input. If the learner becomes accustomed to following the steps in the model, s/he can uncover information and understanding to which they did not have conscious access previously either with a peer or alone.


DEBRIEF model



Describe events as factually as possible

Evaluate what went well/to change next time

Bring out emotions/values/beliefs/assumptions that cloud judgement and development

Review and analyse in light of previous experience; what a colleague would have done

Identify lessons learned

Establish follow up actions

Feedback on actions


©Hayley Allan 2009


Fig 2 DEBRIEF model
 
How does DEBRIEF work?

DEBRIEF is more than reflection. It is a series of questions asked of the learner which promote recall of the events, evaluation of his or her role in the events, and a psychological review of the impact of the events on the learner’s sense of wellbeing, before addressing the cognitive impact and reviewing the account for previous similarities of behaviour. Often perturbations (Piaget 1954, 1971) occur because we repeat behaviour which is a function of emotional or psychological triggers from past experiences. It is only when learners can look back in a safe environment, knowing that whilst they may have made mistakes they also had a positive effect on some of the events concerning them, that they are free to own those mistakes. Emotions can block cognitive development and progress and so the examining of the feelings, beliefs, assumptions or motives behind the learner’s actions is often a pivotal point at which the individual unblocks that repetitive behaviour or identifies the gut feeling causing the perturbation. Being able to move onto action planning as a result of the identification of what has been learned is a positive and valuable way for the learner to move on from the event.

How does DEBRIEF differ from regular reflection?

Reflection often follows the Learning cycle of Kolb (1984) but rarely bridges the gap between the action and reflection stages or between reflection and theory stages. Most learners are not able to make those large transitions alone without additional structure.

Fig 3 Kolb’s reflective practice cycle

Fig 4 Kolb’s cycle with DEBRIEF added

DEBRIEF provides a step wise structure to enable the learner to progress through each of Kolb’s learning points, but looking in turn at the behavioural, psychological and cognitive elements of the practice. By following these steps when reviewing an experience the learner is not only processing the experience itself, but is also developing metacognition which will enable further reflection on future experiences.

Building on Pendleton

Many trainers use Pendleton’s rules in discussing performance with trainees. Pendleton’s central tenets are learner comments preceding trainer’s comments, and positive features preceding developmental areas. This is included in the second step of the DEBRIEF model in order to review the actions taken and behaviour used. Without the emotional and cognitive areas of the experience being looked at too, the feedback can remain formulaic and focused on the surface actions rather than the motives or thinking underlying them.

The impact of DEBRIEF on learning

DEBRIEFing makes learners feel in control of their work; by instigating the process and by learning from an honest DEBRIEF, a trainee can relate to the strengths and areas for development within their practice, can understand the psychological impact of events and is able to access theoretical, emotional and practical developmental strategies to change that work for the better. Ownership of learning, especially in the workplace is a fundamental driver for progress. DEBRIEFing using this structure is a versatile process. A Case Based Discussion can easily turn into a DEBRIEF session as can using Pendleton’s rules for feedback. A learner can seek out a supervisor, more experienced colleague or a peer and discuss the event using the model outlined here. Alternatively the model can be applied to the event independently, using honest self disclosure to explore the issues and impact.

Conclusion

In a postgraduate medical training world where the pressure upon the trainers to teach has never been greater, but the time for teaching has never been more limited, the DEBRIEF model equips learners to structure and guide their own learning, utilising their supervisors, senior colleagues, peers and their own reflections to make sense of their daily experiences. Learning by pattern recognition is no longer tenable; smaller numbers of experiences carry greater pressure on trainees to learn and develop. DEBRIEF offers a comprehensive model for them to do this.


Bibliography

Boekaerts M (1993) Being concerned with well being and with learning Educational Psychologist 32(3) 137 - 151
Brooks JG & Brooks MG (1993) In search of understanding: the case for constructivist classrooms. Alexandria VA, Association for Supervision & Curriculum Development
Friere P (1970). Pedagogy of the oppressed. New York: Continuum
Goleman D (1995) Emotional Intelligence New York Bantam books
Gross M et al (2008) Emotions and feelings in learning process: Understanding emotional learning experiences of Postgraduate students ESREA Life History & Biography Network conference, Canterbury Christ Church university, UK http://tallinn.academia.edu/MarinGross/Papers/253692/Emotions_and_Feelings_In_Learning_Process_Understanding_Emotional_Learning_Experiences_of_Postgraduate_Students
ISCP 2010 https://www.iscp.ac.uk/home/principles_intro.aspx
Lave J, Wenger E (1991). Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press.
Le Doux J (1997) The Emotional Brain: the mysterious underpinnings of emotional life New York Simon & Schuster
Love PG & Goodsell A (1996) Enhancing Student Learning: Intellectual, Social and Emotional Integration by Love. ASHE-ERIC Higher Education Report series 95-4, (Volume 24-4), http://www.ntlf.com/html/lib/bib/95-4dig.htm
Kolb D A (1984) Experiential Learning: Experience as the source of learning and development. Prentice-Hall.
RCP 2011 http://www.jrcptb.org.uk/assessment/Pages/Workplace-Based-Assessment.aspx
RCPath 2011 http://www.rcpath.org/resources/pdf/definitions_of_assessment_tools__ar.pdf
Pendleton’s Rules http://www.gp-training.net/training/educational_theory/feedback/pendleton.htm
Piaget, Jean. (1954). The Construction of Reality in the Child. Translated by Margeter Cook. New York: Ballantine.
Piaget, Jean. (1971). Psychology and Epistemology: Towards a Theory of Knowledge. Translated by Arnold Rosen. New York: The Viking Press.
Sylvester, R. (1994). How emotions affect learning. Educational Leadership, 52(2), 60-65.
Vygotsky, L.S. (1978). Mind and society: The development of higher psychological processes. Cambridge, MA: Harvard University Press.
Wood, D. J., Bruner, J. S., & Ross, G. (1976). The role of tutoring in problem solving. Journal of Child Psychiatry and Psychology, 17(2), 89-100.

Feedback for Learning (FfL)

We still haven’t mastered feedback to drive learning. In the medical world, feedback is seen as a commodity rather than a learning process. This needs to change.

A friend and colleague of mine says that feedback is the oxygen to the soul and that we shouldn’t make people gasp for it.

How true it is that many of us out there are wheezing for some guidance as to how we are doing? We work too often in the dark with little idea of how well we are doing or what we are getting away with that could be better.

“Feedback is the corner stone of effective clinical teaching.” (Cantillon & Sargeant 2008)

This kind of statement is rife in medical education and whilst it is not untrue, it gives little away about what feedback is, how we should approach it, who is best placed to engage in it and when that should happen.

A recent article in Medical Education (Archer, Jan 2010) says that, “Only feedback seen along a learning continuum within a culture of feedback is likely to be effective.” Whilst I agree with this statement most emphatically, I am not sure the article goes far enough in its portrayal of feedback for learning. (FfL)

We have moved over the last decade away from assessment being for the stakeholders only (summative assessment) to a position of using formative assessment to diagnose learning need and to instigate actions to develop and train. (WBAs exemplify this.) What we haven’t quite achieved is the recognition that feedback is not an outcome but is, if it is to facilitate reflection and development, a process. We may talk about the feedback process but most often the result of that process is what is seen to be most important. We still refer to a “critique” of a performance, piece of work or discussion, where the feedback becomes a commodity to be recorded by the trainee. Whilst this outcome based view of feedback persists, it will never fully work as a training and learning tool.

For effective feedback to work in terms of developing knowledge and understanding, attitudes and perspectives and behaviours and actions, it needs to be seen as a process, not an outcome.

This is not a new idea. In 1983 Schon said: “To achieve effective feedback, the health professions must nurture recipient reflection-in-action.” More than 25 years later this is still not happening.

Archer begins to address this but fails to go beyond the outcomes model. He draws a distinction between feedback as directive or facilitative in nature, explaining that “directive feedback informs the learner of what requires correction. Facilitative feedback involves the provision of comments and suggestions to facilitate recipients in their own revision.” In most cases of facilitative feedback the recipient will still focus on the facilitator’s suggestions and comments as the outcomes that must be achieved.

In directive feedback the educator generally tells the trainee how they have done. The trainee then has to understand what has been said, deal with the emotional response that may invoke in him or her and then accept or reject the comment. Acceptance and rejection often have more to do with the emotional response than with the accuracy and relevance of the comments made. In this way what is intended by the educator can often be greatly misinterpreted by the trainee.

Similarly in facilitative feedback, the comments and suggestions, albeit perhaps more acceptably and sympathetically offered, are still dealt with in the same way by the recipient, and may also be interpreted very differently.

Archer claimed that we need to “build on self monitoring informed by external feedback.” I would go further and say that as trainees progress, we need to build on self monitoring within a process of reflective conversations using open questions to guide and develop. Archer says that “the ability to shape capability through self monitoring with self directed assessment seeking requires an individual to accept the feedback provided. “ But if the feedback process is a process where the recipient has to do all the thinking, and the facilitator merely asks appropriate relevant open questions, then there is no feedback to be accepted, except the recipient’s own.

Feedback for Learning (FfL)

What is required is a third form of feedback during which the educator or facilitator does no “telling” whatsoever. Instead the focus is entirely on the trainee, and the trainee does all of the work. Feedback is facilitated with a series of open questions. As a result the learners have to think evaluatively about their experiences. They provide information regarding what they have done or not done, to which they may still have an emotional reaction, but which cannot be immediately rejected as it is they who have stimulated it. To any emotional or difficult reaction the facilitator responds supportively and with questions concerning further actions. In this way the facilitator of the feedback is seen as a helper and supporter of learning, not a critic. The role of the educator is then to move the learner forward to consider ways to address, amend or develop practice for the future.

Archer recommends that feedback is done by trained facilitators and discusses a useful model for scaffolding feedback:

1. Motivate the learner
2. Deconstruct the task
3. Provide direction
4. Identify gaps between actual and ideal performance
5. Reduce risk
6. Define goals

This framework is helpful but still focuses on the facilitator of the feedback as the one who drives the process.

If we return to the model of feedback using open questions only (FfL), we can add to Archer’s scaffolding model with some suggested open questions to elicit learning reflection and thus learning driven feedback.

1. Motivate the learner
• What would you like to get from this review session?
• How do you see this review contributing to your practice?

2. Deconstruct the task
Tell me:
• What happened/what you did
• How you felt/what you assumed/what you believed would happen
• What you think about this experience/have you had this happen before?

3. Identify gaps between actual and ideal performance
• Describe the differences between what you did here and what you would like to do in -x- time?

4. Provide direction & reduce risk
What next steps can you set yourself for this?
How will you do that? Who may you need to help you?

5. Define goals

• Jot down the goals you have set yourself here, along with the time scales, who is involved, where and when you will achieve them and how you propose to review and monitor them.

Previously trainers have been reluctant to use only open questions as they say that the feedback then relies on the honesty and perception and insight of the trainee to identify where they went wrong. It is indeed true that if the trainee is unconsciously incompetent they will not be able to identify errors and ways to develop. However, the skill in using open questions means that the facilitator can enable the trainee to identify that unknown area through questioning and elicitation. This is a skill which is not endemic to all trainers. Therefore the skill must be developed in trainers as well as in trainees.

FfL as professional reflection in action

Feedback is the pre cursor to professional reflection in action. As children we are disciplined so that as adults we develop self discipline. Junior doctors – or anyone starting off in a profession, need to develop professional reflection on and in action in order to function as independent practitioners after some time. If feedback continues to be a commodity that is bestowed from on high, the dependence of trainee upon trainers will never diminish. As educators our role is not just to train, pass on wisdom, transmit knowledge and skills, but to develop the trainee to become critical thinker, reflective practitioner and measured decision maker.

As a consultant surgeon I worked with this week said to me, “I want to teach them to think for themselves.” We can only do this if the feedback we engage in makes them think for themselves. Feedback for Learning offers a process to enable that to happen


Archer J, State of the Science in Health Professional Education. Effective Feedback: Medical Education 2010:101 – 108
Cantillon P, Sargeant J, Giving feedback in Clinical Settings BMJ 2008: 337a 1961
Schon D, From technical rationality to reflection in Action in Schon D, The Reflective Practitioner: how professionals think in action. London basic books 1983 21 - 75