Undergraduate orthoptic students ’ perception of feedback during clinical placement

Aims: The aim of this study was to explore undergraduate orthoptic students’ perceptions of feedback during clinical placement to allow the identification of common themes which could ultimately inform some guidance for tutors in the provision of feedback. Methods: This was a qualitative small case study conducted using semi-structured interviews with eight second year undergraduate orthoptic students from the University of Sheffield. All participants were female. Participation was voluntary and informed consent was obtained. Results: All students described some positive experiences of feedback during clinical placements. All students described at least one experience which they felt had been poor, and some commons themes of positive and negative experiences emerged. Conclusions: Students want an enjoyable placement where they feel able to practise their clinical skills in a safe environment and receive feedback from approachable tutors who do not undermine their confidence. They want a feedback process which is timely, honest, specific, offers ways to improve and reinforces positive behaviour. The feedback process should be made explicit to students so that both tutors and students are clear when feedback is being given.


Introduction
Undergraduate orthoptic students are sent on blocks of clinical placement at orthoptic departments around the UK throughout their three year university training course.This allows each student to put into practice the skills they have learnt at the university, allowing them to practise their skills on patients with genuine orthoptic problems in a supervised setting.Students are also able to learn other aspects of clinical practice such as communication skills and professionalism.In addition to a learning experience, the placement also provides a work-based assessment of the student's clinical skills against set criteria determined by the university.The student's formative assessment should contain feedback to guide the student's learning and assist the student in their future clinical placements.
Workplace learning is a well documented form of education and students learn by an apprenticeship model. 1 Students make meaning of skills by participation and reflection and becoming part of a community of practice, 2 led by an expert practitioner. 3Adult learners welcome feedback, 4 especially when it is based on their performance and tailored to their goals, and it has been shown that learners who receive some type of acknowledgement from their teacher, or some indication of whether their work is correct, are more likely to maintain interest. 5 student's previous experience will determine their approach to learning and therefore the extent to which they engage with tutor comments. 6The value of the feedback depends on the student's understanding.Students who do not yet share a similar understanding of academic language as the tutor would have difficulty in understanding and using the feedback provided.Students have been found to interpret comments differently from the meaning intended by the tutor. 7his is thought to be as a result of the implicit assumptions held by the tutors and students about what constitutes subject knowledge.Academic and clinical tutors are likely to hold assumptions about their students' ability to interpret their comments.
Anecdotal reports suggest that undergraduate orthoptic students have not been satisfied with feedback during placements.The aim of this study was to explore undergraduate orthoptic students' perceptions of feedback during placements to allow the identification of common themes which could ultimately inform some guidance for tutors in the provision of feedback.

What is feedback in a clinical setting?
Feedback is an informed, non-evaluative and objective appraisal of performance aimed at improving clinical skills. 8It is vital to the progression of the student and should be an integral part of teaching. 91][12] High quality feedback is associated with learners' perceptions of high quality teaching. 136][17] When students are given feedback in a non-constructive way this may have detrimental consequences to their learning.
A literature review using the ERIC (Education Resources Information Centre) database and Google Scholar between February 2009 and August 2012 found no published literature relating to the education of undergraduate orthoptic students in the United Kingdom, or to the process or perception of feedback during orthopic clinical placements.

Methods
This qualitative small case study was conducted using semi-structured interviews lasting 30-45 minutes with undergraduate orthoptic students from the University of Sheffield.Ethics approval was granted by the University of Leeds Research Ethics Committee as the research was undertaken as part of a Masters course based at the University of Leeds.Participation was voluntary and informed consent was obtained.
Eight second year students were recruited who, at the time of interviews, had completed five clinical placements comprising of fifteen weeks in four different clinical placement centres per student.All participants were female.The author had initial difficulty in recruiting students to the study; therefore stratified sampling was not possible.The author had no knowledge of the ability level of the students who volunteered.Each interview was recorded and transcribed fully by the author for data analysis and themes were identified.
A qualitative method was chosen as this allowed the researcher to gain an in-depth understanding of the behaviours and thought processes of the study participants.Semi-structured interviews were chosen as this method allowed the author to ask the same questions of each student, but also to explore themes and topics as they arose with additional questions.Open ended questions were used to allow the student the opportunity to discuss their opinions on the subject matter.
The questions asked were determined by the themes identified by the author from the literature review.This included questioning the students about their general experiences of feedback to date, what they felt constituted good and bad feedback, what type of feedback they felt was most useful, what they perceived as potential barriers to feedback and what they would change about the way feedback is given.
Data analysis was undertaken solely by the author using a recognised process for the analysis of interview data. 18The recordings of the interviews were transcribed word for word and examined for common themes, similarities and differences across all participant responses.

Results and analysis
All students described some positive experiences of feedback during clinical placements.All students described at least one experience which they felt had been poor, and some common themes of positive and negative experiences emerged.The results will be examined taking each of these themes in turn and pertinent quotes from the interviews are included to illustrate the points discussed.Numbers of students describing each theme are given where possible, but the students' experiences varied from one placement to another and varied between tutors within the same department.Some of the themes are more general therefore, and it is not possible to state on how many occasions this theme was experienced by each student.

Perceptions of feedback received to date
All students recognised the importance of feedback during placement and felt that receiving feedback from qualified staff was the best way to enhance their own practice.
The whole thing I personally work towards on placement is getting feedback.I want to be the best clinician I can and the only way I can do that is by getting feedback on how I do on placement from the staff.
All students identified useful feedback as being constructive and telling them how they could improve, particularly in relation to their learning outcomes.Students seemed to appreciate the honesty of their tutors in giving them constructive feedback and recognised that this was done in good faith to help them to develop into a better practitioner.
Most students commented that feedback was generally given at appropriate times during the placement and this enabled them to improve their skills gradually over the course of the placement.
All students cited a minority of poor experiences during placement, mostly relating to barriers to feedback including lack of time for feedback, the perceived unwillingness of the tutor to give any specific feedback, and perceived problems with the attitude of the tutor towards the student.
One student perceived that she had not received any feedback during placement at one centre.Further questioning revealed that she had been given continuous feedback but as the feedback given to her had not been clearly labelled she had not recognised the process taking place.This perception is documented in the literature. 19This student reported this experience as being negative and this highlights the perceived importance of making the feedback process explicit to students.

Timing of feedback
During the course of the interviews students described a preference for receiving immediate feedback at the end of each clinic session, or the end of the day.Some liked it after each patient, but others commented this might make them 'dwell on mistakes' they may have made and distract them when seeing their next patient.Students stated the timing of the feedback was important so they could rectify their mistakes sooner rather than later and progress as much as possible in the placement.
All students had experienced timely feedback on the majority of their placements but all cited some experiences where this had not been the case.All students recognised that clinical time pressures were a barrier to feedback taking place and this was cited as the main issue where feedback had not taken place at the time they wished.All said that they did receive the feedback from that session or day eventually, either verbally at a later stage in the placement or in a written format the following day.Most were not too troubled by receiving it later on, but two students felt this was a disadvantage as they had 'forgotten exactly what happened with the patient' or 'it meant I couldn't put that [clinical skill] into practice straight away'.
Four students felt that some placement centres did not give them enough feedback early in the placement to help them to improve their skills to the maximum.One student felt that this may be because clinical placements are relatively short and tutors may be allowing students to settle into the routine of placement, both geographically and in terms of seeing patients, before providing real feedback.One student described a more unusual experience where a placement centre had stated they would not provide any feedback until the final assessment day to allow the student to experience what it would be like to be working after graduation.The student felt more relaxed in clinic and enjoyed the placement but did not find it useful for developing her clinical skills.This illustrates the importance to students of receiving feedback during placement, but also suggests that some tutors may not fully appreciate their role in the education of students on placement.

Mid-placement feedback
All students welcomed a more formal midway feedback session to address any issues before the final assessment and the group was split equally into those who had received midway feedback and those who had never experienced it.Some students felt that this motivated them during placement and encouraged them to push themselves to achieve more.
Five students who had experienced midway feedback had also been given an idea of their mark at that stage and had found this useful: It really helps 'cos you can see exactly where you're at and what you need to do to pass.It helps focus you and you can work with the tutor on those bits that you need to do better on and then you can work on pulling your mark up.
Students who felt that a midway mark would be destructive seemed to be lacking confidence and felt under pressure during the placement.Perhaps these students are weaker in their performance and feel that being forced to acknowledge and quantify their weakness in the middle of the placement could be unhelpful for their confidence: I wouldn't want to know my mark.It's going to change anyway by the end.I don't have much confidence on placement so if it was lower than I wanted then it would stress me out more.
It is clear that providing this midway formative feedback is important to students, but tutors should judge whether to discuss summative mark at this stage dependent on the individual student.From the data, it seems that those students who are achieving a good level of clinical competence benefit from knowing a mark as this boosts their self esteem and drives them to endeavour to achieve a better mark.The possibility must also be acknowledged that there may be some very competent students who are given a good mark at the midway feedback and then become complacent resulting in a lower final mark.It is also possible that weaker students may be demotivated by receiving a mark which may have a negative impact on their confidence.
Three students commented that tutors only really gave them constructive criticism at the end of the placement assessment when it was too late for them to rectify their errors.Students felt very unhappy in these circumstances and felt that they had not been given the opportunity to improve their skills during the placement.This led to a perception that there was too much emphasis on the placement being assessed and not enough appreciation from tutors of the usefulness of a placement as a learning experience to enhance clinical skills.

Feedback versus assessment
Nearly all students were unclear about the difference between feedback and assessment or didn't feel that there was a difference.One student commented that 'feedback is the precursor to the assessment'.One commented that she got feedback on a day-to-day basis from the clinical tutor and then at the end the lead clinical tutor pulls it all together into the assessment.Only one student explicitly identified the difference between feedback and assessment as feedback being a developmental aid to learning.Seven students felt there was too much emphasis on assessment during placement and the assessment process seemed to be driving their learning.Many did not see the feedback given to them throughout placement as developmental but as continuous assessment, and some found this put them under pressure and perhaps reduced their ability to learn.Some students perceived that this could adversely affect their final mark.This perception was strengthened when tutors cited errors made early in the placement in their final assessment.I forgot to look at fixation in one patient in my first week but I did it in all the others I saw and then in my assessment it said that I'd forgotten it.I'd done it loads since then but it's like none of that mattered 'cos I'd missed it that once.Some students felt that their feedback did not always seem to fit with the final clinical competence mark they were awarded and they found this difficult to comprehend.Some felt that the feedback they had been given was very positive with little criticism, but they were then awarded an average mark which was perceived to be unjust.One student did not really seem to understand how the university marking scale differs from a typical 1 to 10 scale, commenting that if you got a 5 on placement it meant that you gave an average performance, but that you'd done as much right as you'd done wrong.This shows some lack of understanding by the students with regards to the marking schemes.It is important that the students comprehend the scales against which they are being assessed in order for them to perceive the assessment as being fair and just and understand their progress throughout the course. 20edback in the presence of a patient Six students agreed that they did not want to receive feedback on their clinical skills in front of a patient: A couple of times I've been told I've done something wrong in front of the patient and I hated it.I felt like I'd lost confidence with the patient, and they've lost confidence in me.
Students agreed that they did not want to be undermined in front of a patient, but all acknowledged that there would be occasions where a tutor had to comment on a testing procedure in front of the patient as a learning opportunity for the student.Some acknowledged that the patient had consented to see a student and would therefore be aware that they would 'not be perfect'.The approach of the tutor is key to the student's perception of feedback in this situation.The tutor must always approach this situation with care, ensuring that the student's dignity is maintained and that the patient continues to have confidence in the student's ability, the tutor as a clinician and supervisor, and the clinical episode as a whole.Some students had examined patients unsupervised.They felt that, although it was a confidence boost to be left alone with a patient, they valued more specific feedback which was only possible when they were being supervised.

Type of feedback
All students agreed that a mix of verbal and written feedback was most helpful.All said it was useful to be able to reflect on written feedback, but all also wanted the opportunity to discuss it with a tutor to ask any questions of clarification and go into more depth.
Students were aware that some placement centres keep a written record of the student's clinical performance but do not allow the student to see it.This was seen as unfair, and students wanted to see this record even it was 'brutal and truthful' as they felt 'it's better to see it than not know what's been written about you all day'.It is unsurprising that students do not like this as it contradicts the ethos of good clinical teaching with regards to provision of open constructive feedback.
Some students reported a difference in the emphasis of verbal and written feedback.
I sometimes find they're not the same… the written feedback seems a bit more picky and they put stuff they never mentioned when we talked… that's not fair 'cos they're telling you what you've done is good then contradicting themselves in the book… I think they feel negative things have to be written down as well… it's good 'cos it's all helping you but it's a bit of a cop out to write it down and not say it.
Perhaps some tutors find it easier to write negative feedback rather than give it face to face.Tutors may not want to confront the student, or deal with the student's reaction to negative feedback.
On the whole, students seem to like to discuss feedback with their tutor at the time of the clinical episode.They also like a written record to reflect on, and feel more satisfied when the verbal and written feedbacks concur.

Feedback across the country
Students valued having a lead clinical tutor who they worked with the majority of the time, as they developed a better rapport with the tutor and felt more at ease.They all agreed that they would not want to work solely with one tutor throughout the placement, and that input from other staff was valuable.
Most students reported that the type and amount of feedback was consistent between tutors in the same department, although it was felt that the lead clinical tutor was much more thorough with feedback than other staff.
Students reported a wide range in the type and quantity of feedback given between different departments across the country.Students seemed to prefer more thorough feedback, even though it was perceived as being more stressful at the time: Some departments are more thorough than others… some just say you're doing fine and others are really picky.It's nice when they're relaxed but I find it really frustrating if they're not specific.I just want to know where I'm at so I know how I'm going.

Tutor attitude
All students felt that the attitude of the tutor could be a barrier to effective feedback.Two students reported receiving purely negative feedback from tutors on a 'power trip'.The behaviour described by these students included the tutor not listening to the student, raising their voice to the student, a perceived feeling that the tutor was trying to make them feel stupid and humiliate them in front of the patient, and the tutor belittling what the student said.They cited this as 'unhelpful' and 'soul destroying'.It is possible that these students are weaker students who have been unhappy with the negative feedback they have received, or there may be a minority of clinical tutors who are behaving in an unacceptable and unprofessional manner towards students.This behaviour may be as a result of a personality clash between tutor and student, combined with pressures of a busy clinic.Teaching by humiliation is a well-recognised concept in medical literature and is documented as poor practice so must be discouraged within healthcare education. 21onversely, one student felt that tutors being too nice could be a barrier to effective feedback: …one tutor was really lovely and I like being with her in clinic but she was just a bit too nice.I was trying my best to find out where I could improve, but she just kept saying I was doing fine and to carry on.I wanted her to ask me more in depth questions so I could prove myself or find any gaps in my knowledge but she wouldn't and I think that stopped her from really finding out what I was capable of.This tutor may have avoided giving negative feedback so as to preserve a good relationship with the student.However, when negative feedback is withheld the tutorstudent relationship is superficial and lacks flexibility to tackle sensitive issues. 22It is possible that this tutor may lack confidence in her own skills as a tutor, but perhaps also as a clinician and perhaps did not want to reveal any of her own weaknesses to the student.It is also possible that this tutor may feel that her own theoretical knowledge is not sufficiently deep to fully question the undergraduate students.

Student attitude
Two students identified that student attitude was important in facilitating effective feedback.One commented that students 'have to be open minded and able to take constructive criticism without taking it too personally'.One said it was important for the student to work with the tutors to help themselves improve and recognised that tutors may give up trying if the student didn't work with them to achieve their goals.This shows the appreciation of feedback as being a two way process by these students and that they recognise that it is necessary to engage with this process in order to develop their skills.

Discussion
All students recognised the importance of feedback during a clinical placement and felt that receiving feedback from qualified staff was the best way for them to enhance their own clinical practice.This shows a level of maturity in their appreciation of feedback as an opportunity to improve practice and rectify their weaknesses.The majority of students interviewed reported receiving useful feedback from committed clinical tutors throughout placement which allowed them to put into practice and build on the skills they had learnt at university.
Students want an enjoyable placement where they feel able to practise their clinical skills in a safe environment and receive feedback from approachable tutors who do not undermine their confidence.They want a feedback process which is timely, honest, specific, offers ways to improve and reinforces positive behaviour.This is consistent with published research relating to other healthcare professions that acknowledges the importance of these factors to students.
All students expressed a desire to have a more formal midway feedback session with their lead clinical tutor which followed a similar format to the final assessment.Most felt they would like to know a guide mark at that stage where relevant.Those who hadn't received it felt as if they had been disadvantaged in comparison to students on other placements who had the benefit of this more structured feedback session.This session makes the feedback process explicit to the student and allows them the opportunity to acknowledge and rectify any errors during their time on the placement.This is perceived as a more fair way of presenting feedback as the students feel that they would be told of ways of improving and rectifying errors prior to the final assessment.
It is concerning that some students report placements where little feedback is given.This may be that the student does not recognise the feedback taking place, or it may be that some placement centres are not providing sufficient feedback to students.This could be due to the constraints of teaching students within a busy clinic, or there may be some lack of understanding by some tutors with regard to the learning and assessment processes during placement.
It is very worrying that some students report experiences of clinical tutors behaving unprofessionally towards students.This does not create a pleasant, constructive or supportive atmosphere in which a student can learn and inhibits the student from feeling able to ask for guidance when they need it.
Following consideration of the points raised by students the following guidelines are recommended: .Clinical tutors should endeavour to provide honest, specific, timely, constructive feedback to undergraduate orthoptic students.This should include guidance on where the student can improve their skills. .Feedback should be given verbally to the student and also be provided in a written format in order to promote student reflection. .Feedback should always be provided in a supportive way to aid student development. .The feedback process should be explicit and the student and tutor should be clear when feedback is being given. .A structured feedback session should be included at the midpoint of placement which follows the outline of the final assessment.A guide mark could be provided at this stage if both student and tutor felt this was appropriate.

Limitations
Limitations of this study include a small sample size and the voluntary nature of selection of participants.Students were recruited from only one of the two universities offering the orthoptic degree course at the time the research took place, due to the geographical location of the author and constraints around time to conduct the interviews.As both universities send their students on blocks of clinical placements, and there are limited clinical placement sites across the country, it was felt that the same themes would emerge regardless of the students' study base.It is acknowledged however that there are differences in the clinical placement assessment process between the two universities which offer the course.
All students were in their second year of study at the time of interview.It was not possible to recruit any students from the third year of study as the author's clinical commitments and the third year students' clinical placements and examination timetable were not compatible.
Students who volunteered to participate may be more motivated students or those who have had extremes of experiences during placement and therefore felt more compelled to discuss their feelings towards this.Their views may not therefore be representative of the student body.
All volunteers were female, and whilst the orthoptic profession is primarily female there is approximately a 20% intake of male students into each year group who were not represented in this study.

Conclusion
The students interviewed reported mostly positive experiences of feedback during their placements.However, they had all personally experienced at least one episode of feedback during a placement which they felt was negative.
Students want an enjoyable placement where they feel able to practise their clinical skills in a safe environment and receive feedback from approachable tutors who do not undermine their confidence.They want a feedback process which is timely, honest, specific, and offers ways to improve and reinforces positive behaviour.The feedback process should be made explicit to students so that both tutors and students are clear when feedback is being given.
One student succinctly summed up the feelings of most of the students interviewed: I'd just like tutors to be aware how important feedback is.You should be positive in giving feedback as well as critical, but always be honest and tell us ways to improve.Placement can really knock your confidence if you have a bad experience, and bad experiences are usually because of the way feedback is done.
Assessment is where they're telling you what you've done good and what you've done bad and that's it.Feedback is them telling you what you've done good and what you've done bad and what you should do to make it better.