Developing residents’ feedback literacy in emergency medicine: Lessons from design-based research.

Content: blog, factsheet and Q&A with teh authors. Lets start! Do your students (nurses, doctors, police officers e.t.c.) know how, from whom, when and when not to retrieve effective feedback while on the job? Do we as first responder trainers/teachers think too easily about feedback and debrief? Me and my colleagues often talk about the need for feedback (and debrief) to our partcipants. Sounds good but what if our participants don’t know how to initiate effective feedback conversations at work? Yes, initiate because we don’t want them to be a passive receiver but the owner of their own learning process. But do they how and when and from whom to retrieve feedback that goes beyond what’s next, work harder or get more experience? Did we teach them how to gain visibility into the opportunities with the greatest potential for feedback? We can promoting a 30 minute feedback or debrief conversation to our learners in training but when the practice consists of a busy ER/ED with dozens of patients waiting to be seen this will not happen in real life. This research is an attempt to gain more insight into the facets that increase the likelihood of effective feedback for the learner in real life circumstances where the stakes are high. See also the researchers’ fact sheet at the end of this blog about the best time, best place, best person and so on to whom to ask for feedback!

Goal of the research

” Residents in emergency medicine have reported dissatisfaction with feedback. One strategy to improve feedback is to enhance learners’ feedback literacy—- i.e., capabilities as seekers, processors, and users of performance information.

To do this, however, the context in which feedback occurs needs to be understood. We investigated how residents typically engage with feedback in an emergency department, along with the potential opportunities to improve feedback engagement in this context. We used this information to develop a program to improve learners’ feedback literacy in context and traced the reported translation to practice”. (1)


“Our findings suggest that the development of feedback literacy through a dedicated program contributes to residents’ conceptual understandings of what productive feedback could look like in this setting.

It went some way in improving their ability to initiate and engage more effectively in feedback conversations, e.g., to be better at asking for information to improve future performances rather than waiting for the delivery of a summary of what the supervisor observed”. (1)

It is not that easy

“However, developing feedback literacy for high-stakes and fast-paced environments was more nuanced than initially anticipated. The residents, despite their best efforts, found that there were contextual factors that made it challenging to advance feedback processes, e.g., exhaustion or hectic work schedules, workplace busyness, and respecting the competing priorities observed in supervisors”. (1)

Adapt to reality

“In response to these factors, residents adjusted their approach to feedback engagement from moment to moment. This dynamic decision-making about when to interrupt, and who to interrupt for what information, gave us a better understanding of what it means to be a feedback literate resident in the ED”. (1)

Chaning mantra’s

“Our initial mantra was to “get active in feedback.” However, the cycle iterations suggest that feedback literacy is not just about “getting active” (or proactive for that matter) but also to read the environment moment to moment and make decisions about what to ask, what to reveal, to whom, and for what purpose. In other words, we have learned that being feedback literate is more about learning to “pick your moment and pick your person.” Hence, learners develop a more sensitive radar for anticipating the possibilities for what a feedback exchange may produce under different circumstances. For example, some residents reported that they started to develop the skills to reorientate a conversation so that there was a focus on what’s next—beyond “work harder” or “get more experience.” (1)

Feedback legacies

“Finally, learners in emergency medicine are not feedback naïve and instead will have had diverse feedback experiences before coming to the ED and that these experiences may hamper or hinder their feedback engagement. There would be merit in researching how to attune feedback literacy programs to learners’ feedback legacies”. (1)

Quotes from residents I like

“ … it’s really kind of unfair to blame it on the supervisors that they don’t provide the significant [long] extended feedback because of time pressures. We’ve seen the emergency department here. It’s rarely under 250, 300 people [patients] in there in 24 h … I can’t see how a consultant can have time or find time during a busy clinical shift”.

“I think there are a couple of really specific pieces of almost more “clinical pearls” rather than feedback specifically from consultants and things, just like, oh, this is probably a better way to deal with this sort of presentation; rather than, this is a thing that you could improve on, and this is how you could do it. Because usually I found when I tried to get feedback about performance there was; you need to work on it, you just need experience. Which is true but not wholly helpful. “

“I think, take every opportunity you have as feedback because sometimes feedback is not going to be— won’t jump out and you say “it’s feedback!” It’s like actively listening to what other people are saying because if they are receptive to what you’ve done, they often give you feedback through verbal cues and nonverbal cues. Their attitude as well”.

Q&A with the authors Christy Noble (CN) and Victoria Brazil (VB).

What are the roadblocks to good feedback in practice and what can we do about it?

VB:” Roadblocks such as

feedback skills of supervisors ( what to give feedback about and how to have the conversation)

lack of workday structure that automatically incorporates feedback

lack of shared understanding about /cultural expectations about feedback purpose

lack of longer-term trusting relationships between supervisors and residents that gives consistency and credibility to the process

CN:” the other roadblocks are related to how feedback is conceptualised, that is, it is often seen as information provision (supervisor tells the trainee about their judgement of the trainee performance) but, recent evidence, indicates that feedback is two-way process where both parties have an active role to play, and the overall aim is to improve trainee performance.

Why are residents dissatisfied with feedback and what skills do they themselves lack?

VB: “They think they don’t get any feedback, unlike supervisors who think they are giving it. They don’t think it’s their responsibility to ‘extract’ feedback from supervisors”.

CN: ” Supervisors tend to get training on ‘how to give feedback’ but residents don’t tend to get trainee on how to engage in feedback processes.  This means residents often don’t have the knowledge and skills about what an effective feedback interaction and what is their role in the feedback process”.

What was the purpose behind the mantra ‘get active in feedback’ and why has it changed to ‘pick your moment and pick your person?

VB:”Recognising that guidance needs to be more specific and that identifying the right time and person is more likely to help than just saying ‘do better'”.

CN:”The other thing we wanted to highlight in the paper is that when we encourage residents to get more actively involved in feedback, it doesn’t mean that they should be asking everyone for feedback all the time. Rather residents need to be discerning by reading the clinical environment and based on this read, find appropriate times and also people (e.g. some who has observed their work and isn’t too busy to have a feedback conversation).”.

What is the skill to reorient the conversation beyond work harder and get more experience?

VB:”I think its being specific eg “Can you watch me do this procedure and specifically give me feedback on my sterile technique” “I just presented a case – what did you think of my investigation choices”.

CN:” I agree with Vic that there are things the residents can do, and I also think this is a role supervisors can play a role here e.g. share with the resident specific actions the resident can take to improve their performance”.

What do you mean by congruence between feedback program and clinical context?

VB:”There is no point in saying have a 30 minute feedback conversation in the middle of a busy ED with dozens of patients waiting to be seen”.

CN:”The other thing to consider is that different specialities will have different feedback opportunities e.g. in internal medicine it might be more feasible to have a longer feedback conversation compared to ED.”.


1. Noble, C., Young, J., Brazil, V., Krogh, K., & Molloy, E. (2023). Developing residents’ feedback literacy in emergency medicine: Lessons from design-based research. AEM education and training7(4), e10897.