1. Altmiller, Gerry EdD, APRN, ACNS-BC

Article Content

One of the most challenging responsibilities nurse educators face is providing feedback to students that will result in a meaningful outcome when student performance is not meeting expectations. Receiving constructive feedback as a student and as a nurse is essential for personal and professional growth, but for faculty, delivering feedback to students while continuing to nurture the student-teacher relationship can be difficult. Implementing effective communication strategies to deliver constructive feedback can support faculty in this important and necessary work. Failure to do so can negatively impact the learner, act as a trigger for incivility, and have deleterious effects on the professional comportment of new nurses entering the workforce.


Literature Review

The literature suggests that uncivil behaviors are occurring with increasing frequency in nursing education.1 Triggers for incivility have been linked to communication in several studies. Luparell3 identified a frequent trigger of incivility results from feedback given by the faculty member to the student because of poor performance. Hunt and Marini4 categorized subtypes of incivility among nurses in practice, reporting a frequently occurring subtype was retaliation because one feels provoked or offended. Altmiller5 identified a student perception that faculty behavior fuels student incivility, but more alarming was the belief that incivility was justified when students perceived faculty behaviors as uncivil.


Of late, there is an increased emphasis in the literature suggesting that nurse educators not only address student incivility but also reflect on their own behaviors that may be contributing to the escalating incivility in the academic environment.6,7 Faculty behaviors identified as uncivil and fueling student beliefs that faculty have negative motivations include subjective evaluation, rigid expectations, and targeting and "weeding out" practices.8 Demeaning communications from faculty to student, particularly those that occur in front of other students, patients, or staff, are particularly harmful to the student-teacher relationship and thus the learning experience.2,5,8 In addition, the literature suggests that incivility in schools of nursing can lead to a weakened learning environment and poor workforce behaviors.7,9


Role of Feedback

Communicating constructive feedback is essential to the teaching and learning process,10,11 and in health care professions education, direct observation frequently forms the basis for feedback.12 Constructive feedback should provide an unbiased critique of performance, recounting events as they occurred, with the intention to correct errors and increase understanding.13 Speaking in first person, using I instead of you, works to keep the narrative factual and enhance teacher credibility.13,14 When effective, constructive feedback can serve as a motivating factor.15


Most nurse educators are comfortable providing reinforcing (considered positive) feedback, but significant barriers exist to giving constructive or corrective (considered negative) feedback. Some educators are concerned that it will result in poor evaluations14 or create conflicts.13,14 As a result, some educators avoid providing substantive critique.13 How then can nurse educators provide meaningful feedback to support knowledge and skill development while nurturing the student-teacher relationship?


Techniques to Deliver Constructive Feedback

Giving constructive feedback is a skill that requires practice.13 Whether positive or negative, it should always be an unbiased reflection of events that provides logical connections. Delivery style plays a key role in whether a student accepts, modifies, or rejects feedback. Past experiences can influence how students respond to feedback,14 so nurse educators should model the behavior they wish students to adopt. Timely delivery, identifying it as an opportunity for learning, and immediately providing options for improvement increase its effectiveness and teach the student to view it as an opportunity for personal improvement. Should a discussion begin to escalate, faculty should model an appropriate response, maintaining civility in the face of incivility, by speaking calmly and staying focused on the concern being addressed.


Providing feedback indicates one's commitment to another's success and emphasizes the importance of what that individual is doing.16 Unfortunately, this sentiment frequently gets lost in the message. Beginning with a caring statement clarifies faculty motivations and allows the student to feel safe, decreasing the need for defensiveness. An example is to begin the discussion with "I asked you to meet with me because I care about your success," or "I wanted to talk to you today because I want you to be the best nurse you can be." Educators need to make certain that caring is incorporated into every feedback message as it can strongly influence the student's interpretation and affect the student applying the feedback to future practice.


Nurse educators should frame feedback in reference to course learning outcomes.14 Verbalizing that the faculty member and student have the same goals of professionalism and success builds a relationship between both parties. Nurse educators should take great care to avoid shaming. Such behaviors include correcting individuals in front of patients, peers, and other health care providers; ignoring the individual; and displaying contempt for a student's lack of knowledge. To set parameters for reasonable expectations, faculty should consider whether 2 or 3 peers could have made the same mistake in similar circumstances.


Using the Socratic Method can assist students to reflect on their abilities. Educators can ask students to see events through the patient's eyes. This reinforces patient-centered thinking. Reframing Constructive Criticism Using Reflection Based on the Quality and Safety Education for Nurses (QSEN) Competencies17 is an instrument framed by the 6 QSEN competencies that provides examples of a questioning route instructors can use to guide students in extracting a realistic appraisal of their performance. For example, rather than telling students that their practice was unsafe, the instructor might ask the students, "If you were the patient and knew this happened, would you feel that you were receiving safe care?" Using questions to encourage self-reflection allows the student to arrive at the same conclusions that frequently are communicated directly by the faculty member but may be misinterpreted by the student, acting as a trigger for incivility.


Providing feedback to students can be difficult. Nurse educators can develop expertise by incorporating effective communication strategies. Through modeling, faculty can teach these skills to students during prelicensure education so that students can appreciate the value of feedback in their personal and professional development.




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