Feedback: An essential element of student
learning in clinical practice
Mary P. Clynes1,2, Sara E.C. Raftery*,1
School of Nursing, Dublin City University, Glasnevin, Dublin 9, Ireland
Accepted 10 February 2008
order for the student to benefit fully from the experience regular performance feed-
back is required. Feedback should provide the student with information on current
practice and offer practical advice for improved performance. The importance of
feedback is widely acknowledged however it appears that there is inconsistency in
its provision to students. The benefits of feedback include increased student confi-
supervisor. Barriers to the feedback process are identified as inadequate supervisor
standing of the student response to feedback and effective communication skills.
Clinical practice is an essential component of the nursing curriculum. In
c 2008 Elsevier Ltd. All rights reserved.
Feedback is a fundamental aspect of teaching and
learning. Rowntree (1987, p. 27) describes it as
the ‘‘lifeblood of learning’’. While the importance
of feedback is widely acknowledged there appears
to be inconsistency in the amount, type and timing
offeedbackreceived by students in clinical practice
(Cahill, 1996; Nordgren et al., 1998; McNeill et al.,
1998; Pertab, 1999; Glover, 2000; Gray and Smith,
2000; Raftery, 2001). The aimofthis paperis to out-
line the nature and importance of feedback in the
clinical learning environment. The benefits of and
the barriers to feedback will be explored and finally
the elements of effective feedback will beoutlined.
What is feedback?
There are many definitions of feedback all of which
share common characteristics. All definitions sug-
gest that feedback is an interactive process which
aims to provide learners with insight into their
1471-5953/$ - see front matter ?
c 2008 Elsevier Ltd. All rights reserved.
*Corresponding author. Tel.: +353 1 7007154.
E-mail address: firstname.lastname@example.org
1Both authors contributed equally to this paper.
2Tel.: +353 1 7007152.
Nurse Education in Practice (2008) 8, 405–411
performance. Terms used to describe feedback may
corrective/negative and reinforcing/positive. In
general, however, practitioners tend to use the
terms negative or positive when describing feed-
back. When giving feedback information should in-
clude opinionand judgement
performance and explore options for improved
practice (Wiggins, 1993; Eraut, 2006). Feedback
should be based on observations made while work-
ing with a student in practice and may follow a per-
iod of reflection by the supervisor. This must be an
unbiased, analytical reflection of what has occurred
Both formal and informal methods of delivering
feedback to the student exist. Ideally a combina-
tion of these methods should be used to ensure
ongoing and timely information is given. One infor-
mal method of feedback is on-the-spot comments
which are made during practice. These are used
to offer feedback on aspects of practice which are
observed by the supervisor. The advantage of this
method is that it is most likely to be situation-spe-
cific which ensures that important elements are
not forgotten. In addition, this method lends itself
to discussion of evidence-based practice which
can be instantly demonstrated to the student. This
opportunistic feedback is a vital element of the
clinical learning experience. Many supervisors feel
that this type of feedback is so much part of the
day-to-day activity of the clinical environment that
it is given unconsciously (Clynes, 2004). A potential
drawback of this unconscious process is that it may
not be regarded as feedback by the student thus
negating the process (Eraut, 2006). This problem
can be overcome if the supervisor refers back to
these learning experiences during formal feedback
A second informal method of feedback is general
conversation away from the job. While this tech-
nique may enhance collegiality its value is uncer-
offered. More importantly, it can foster effective
relationships which may prompt the active pursuit
of feedback by the student (Eraut, 2006).
For the majority of student nurses feedback
takes on a more formal dimension whereby they
are assigned a named supervisor who is responsible
for the provision of feedback. This may include for-
mative or summative feedback. Formative feed-
back is ongoing and aims to improve the learning
experience. It does not involve the grading of clin-
ical performance. Summative feedback takes place
at the end of a clinical placement and includes con-
structive feedback and the grading of clinical
Benefits of feedback
Benefits for the student
The impact of constructive feedback extends be-
yond the teaching and learning process. Feedback
is essential for the student’s growth, provides
direction and helps to boost confidence, increase
motivation and self-esteem (Greenwood and n’ha
Winifreyda, 1995; Atkins and Williams, 1995; Baard
and Neville, 1996; Begley and White, 2003). It can
help students rate their clinical practice in a real-
istic way (Glover, 2000). If students are not offered
feedback they may compare themselves with more
senior colleagues and evaluate themselves inappro-
priately. This can lead to decreased levels of stu-
dent self-esteem which may have a negative
impact on subsequent practice. It also provides a
means by which the student can fit in and contrib-
ute to ward activity in a useful manner (Cahill,
1996; Glover, 2000).
Benefits for the supervisor
It is acknowledged that benefits also accrue to
supervisors as a result of providing feedback. It
promotes personal and professional growth and
development (McGregor, 1999; Clynes, 2004).
Supervisors believe that their communication and
through the provision of feedback (Clynes, 2004).
A sense of personal satisfaction is achieved by facil-
itating the development of another person, sharing
practice and enhancing learning (Atkins and Wil-
liams, 1995; Allen, 2002; Clynes, 2004).
Student experiences of receiving feedback
Notwithstanding the evidence that feedback is an
a review of the literature reveals significant incon-
sistency in the amount of feedback, praise and posi-
tive reinforcement received by students (Cahill,
1996; Nordgren et al., 1998; McNeill et al., 1998;
Raftery, 2001). In fact, feedback on clinical perfor-
too late, destructive, and personal in nature (Raf-
tery, 2001). In addition, it frequently fails to con-
centrate on skill development and enhanced
clinical performance. Some students indicate that
praise can be rare, but fault finding which has a neg-
ative impact on self-esteem and confidence is not
(Cahill, 1996). Students suggest that a good supervi-
sor is someone who provides constructive criticism
ratherthan allowing inaccurate practiceto
406M.P. Clynes, S.E.C. Raftery
continue (Cahill, 1996). Unfortunately many stu-
dents are only informed of such inaccuracies at
the end of a placement when they have no opportu-
nity to improve (Raftery, 2001). Overall students
appear to exhibit maturity in their appreciation of
the importance of receiving feedback and value
the opportunity to concentrate on identified weak-
nesses thereby improving practice (Gipps, 1994;
Students tend to rely heavily on their supervisors
to arrange progress interviews and offer feedback
(Cahill, 1996; Daelmans et al., 2006). This may
indicate that student nurses can feel intimidated
by clinical staff and are subsequently reluctant to
seek information and to pose questions (Moore,
1995). Alternatively it may represent a lack of ini-
tiative on the part of the students who are equal
stakeholders in the feedback relationship.
Barriers to giving and receiving feedback
The supervision of students can never occur in iso-
lation from the broader context of the clinical area
in which it takes place. Thus the conflicting de-
mands of providing patient care and student sup-
port are an ongoing problem in the provision of
quality student supervision and feedback (Atkins
and Williams, 1995; Dibert and Goldenberb, 1995;
Wilson-Barnett et al., 1995; Twinn and Davis,
1996; Kaviani and Stillwell, 2000; Ohrling and Hall-
berg, 2000; Allen, 2002; Clynes, 2004). Supervisors
must give priority to patient care which frequently
results in minimal supervision of students. This is
particularly true during periods of intense ward
activity, precisely the time when students require
maximum support and feedback. However, when
the student is supernumerary, supervision and pa-
tient care need not be mutually exclusive. By work-
ing alongside the registered practitioner the
student can learn through a process of observation
Other elements which interrupt the supervisor
student relationship are sick leave, night duty and
annual leave. These disrupt the formal supervisor
allocation systems resulting in the student being
without a supervisor and receiving no feedback un-
less alternative systems are put in place (Watson,
1999; Raftery, 2001). Interestingly, Atkins and Wil-
liams (1995) report that nurses who are committed
to supervising have fewer concerns about managing
conflicting roles and responsibilities. Similarly,
practitioners who are active and interested in elic-
iting and using feedback for their own development
will be likely to engage in the feedback process
with learners (Menachery et al., 2006).
Maintaining positive relationships with students is
valued by supervisors. For this reason some super-
visors avoid giving negative feedback because they
fear that criticism will affect their relationships
with students. In addition many nurses are uneasy
with the process of delivering feedback (Raftery,
2001; Dohrenwend, 2002; Clynes, 2008). In particu-
lar supervisors report the difficulty they experience
in giving negative or constructive feedback. Never-
theless nurses realise the importance of offering
feedback to students and where possible attempt
to do so as they are aware of the consequences
of not providing feedback. When negative feedback
is withheld, supervisor-employee relationships re-
main superficial and lack the necessary flexibility
to tackle sensitive issues which may subsequently
lead to aggressive behaviour due to an avalanche
of pent-up criticism (Dohrenwend, 2002).
Preparation for giving feedback
Preparation for the role of supervisor may also af-
fect the nurses’ ability to give feedback. The need
to prepare staff for the role of supervisor/supervi-
sor is well recognised (Wright, 1990; Philips et al.,
1996a,b; Kaviani and Stillwell, 2000; McCarthy and
Higgins, 2003). Simply assigning named practitio-
ners to students is no guarantee of their ability to
provide effective feedback and thus give the stu-
dent the opportunity to improve practice (Higgins,
2000). It cannot be assumed that a clinically com-
petent practitioner will have the necessary skills
to give feedback to students (Kaviani and Stillwell,
2000; McCarthy and Higgins, 2003). The importance
of specific training in providing feedback cannot be
underestimated. Many training programmes focus
on the documentation that aids the assessment
process and the feedback process is poorly ad-
dressed or overlooked.
The feedback process
It is widely acknowledged that feedback is more
likely to be accepted and result in improved prac-
tice if the information is appropriately presented
to the student (Russell, 1994; Newstrom and Davis,
1997; Dohrenwend, 2002). The effective delivery of
feedback is a multifactorial process which begins
with preparation of the supervisor in the competent
Feedback: An essential element of student learning in clinical practice407
delivery of feedback. Further elements include
establishing objectives with the student, timing of
the feedback, the environment, the language and
format used and the readiness of the student to re-
Preparation of the supervisor
Prior to embarking on the role of student supervisor
it is essential that the nurse is educated and trained
in a method of feedback delivery. Formal training
should include a period of self reflection in order
that any personal attitudes and biases regarding
supervision can beacknowledged.Discussionofper-
sonal experience of receiving feedback, identifying
positive and negative aspects is required. Experi-
on problem solving in the role, should be explored.
The use of role play can assist the nurse to work
through challenging feedback situations in a safe
environment. There does not appear to be agree-
visor effectively and programmes vary in length
from a few hours to a number of weeks. Generally
it appears that in-house workshops are approxi-
mately one to two days in length (Kramer, 1993;
Bain, 1996). It is also anticipated that a significant
number of nurses will have completed a teaching
gree or graduate diploma programmes.
Understanding the student response to
A further consideration for the nurse preparing to
deliver feedback to students is the need to gain
an understanding of how students respond to feed-
back. Factors such as a student’s self-esteem
(Young, 2000), relationships in the workplace and
the expectations of the learner affect how the
feedback is received (Eraut, 2006). Supervisors
need to be cognisant of the relationship between
self-esteem and receipt of feedback. It appears
that students with high self-esteem have a positive
attitude to receiving feedback and being assessed
(Young, 2000). Furthermore students with high
self-esteem have the ability to appreciate con-
structive comments and understand that the infor-
mation relatesto performance.
students with lower self-esteem tend to interpret
constructive comments more negatively and often
perceive them as personal in nature.
A significant consideration when giving feedback
is an understanding that feedback given is not al-
ways the same as feedback received (Eraut, 2006;
Koh, 2007). It is important to remember that infor-
mation the supervisor regards as a comment on
performance may be perceived by the recipient
as a personal slight. Clynes (2004) notes that stu-
dents often do not understand that concerns high-
lighted by the supervisor are directed towards
ensuring improved clinical performance and quality
patient care. In order to assess how the informa-
tion has been assimilated by a student during a
feedback session, it may be useful to have a sum-
mary discussion during which students are encour-
aged to reflect on the feedback and outline their
interpretation of its content.
The relationship the student has with the super-
visor will influence the receipt of feedback. When a
student respects their supervisor and believes that
the supervisor knows them well they are likely to
value the information received (Gillespie, 2002).
In addition, this type of supervisor/student rela-
tionship may encourage the student to seek feed-
back regularly (Eraut, 2006).
On occasion feedback to students may be im-
peded due to supervisor related factors. Despite
careful preparation, anxiety and unease with the
process can inhibit the delivery of feedback to
the student. In extreme cases the supervisor may
delay or completely avoid an evaluation meeting
with a student for fear of a negative response or
over-reaction to criticism. This is particularly true
in the case of a novice supervisor or when difficult
feedback has to be given (Clynes, 2008). Despite
such fears, for a student to progress and in the
interest of best practice, it is essential that the
feedback session takes place. Provided the supervi-
sor is empathic, chooses appropriate assertive lan-
guage and provides negative feedback within the
context of a positive assessment, no responsibility
should be taken for how the student reacts when
the feedback is given (Baard and Neville, 1996).
Naturally students may be disappointed with con-
structive feedback and the supervisor must ensure
that the session includes a positive action plan for
how to move forward and improve performance.
As discussed, informal feedback may take place in,
or removed from, the practice setting. When giving
formal feedback to students it is essential that suf-
ficient time and space are allocated to the process
to ensure that all aspects of practice can be dis-
cussed without interruption. Feedback should be
given in a quiet, private environment. An informal
room layout will promote two-way discussion of the
student’s performance and should foster openness
408 M.P. Clynes, S.E.C. Raftery
and honesty. Ideally, the use of ward treatment
rooms should be avoided due to constant interrup-
tions which can be stressful for both student and
Jerome (1995) describes the feedback process as
occurring in four stages (Fig. 1).
At the beginning of a clinical placement the lear-
ner and supervisor must work together to establish
learning objectives as feedback will eventually be
based upon these (Wood, 2000). When offering neg-
ative or critical feedback it may be useful to use the
‘‘sandwich’’ technique (Dohrenwend, 2002). This
method consists of providing negative feedback
sandwiched between two specific pieces of positive
feedback. This method is particularly useful when
working with junior students and students with
low self-esteem. In situations where there is a very
healthy supervisory relationship it is not always
essential that all praise or criticism needs to be
sandwiched and on occasion it may be more appro-
priate to offer praise and criticism independently
(Dohrenwend, 2002). Mature students with prior
nursing experience do not appear to be overly con-
cerned with the manner in which feedback is given
unlike younger students who may be more sensitive
to criticism (Lee et al., 2002).
Wiggins (1998) describes the best feedback as
being highly specific, and descriptive of what actu-
ally occurred. Information, including examples
from practice, should be clear to the student and
offered in terms of specific targets and standards.
Feedback should focus on evaluating behaviour
and work performance and not on the student’s
character (Russell, 1994; Baard and Neville, 1996;
Newstrom and Davis, 1997; Dohrenwend, 2002).
The importance of asking for the student’s self
assessment before giving feedback cannot be
underestimated as it provides the supervisor valu-
able insight into the student’s ability to evaluate
his or her own performance (Pugh, 1992). The pro-
cess of delivering feedback is considerably easier
for the supervisor when the student identifies their
own practice limitations (Clynes, 2004).
In considering the delivery of feedback Myrick
and Yonge (2002) suggest that gentle rather than
harsh feedback encourages students to become
confident and competent in developing a plan that
achieves safe and effective nursing care. Moreover,
by approaching the student with sensitivity and
taking on a helping, rather than corrective role,
the supervisor assists the student to examine the
prioritisation of their work. Feedback should be gi-
ven in private, when there is ample time and
opportunity for clarification and discussion and
with due consideration for the student’s feelings
(Hewson and Little, 1998; Clynes, 2004; Kelly,
2007). Conn (2002) considers it important not to
confuse feedback with praise as students and
teachers often do. While praise may be conducive
to developing a positive relationship between
supervisor and student, it may not provide the stu-
dent with specific insight into their performance.
Feedback on clinical performance is essential for
effective student learning in clinical practice.
However, students report variable experiences of
receiving feedback while on practice placements.
This may be attributed to a number of factors
including the ward environment and the readiness
and ability of the registered nurse to give feed-
back. Preparation of the registered nurse in the
provision of feedback to students is paramount.
Awareness and understanding of the elements of
feedback delivery can aid the process and ensure
that both supervisor and student have a positive
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Feedback: An essential element of student learning in clinical practice411