Coaching in CBVE
Kathy Salisbury, Purdue University, College of Veterinary Medicine
Karen Cornell, Texas A&M University, College of Veterinary Medicine & Biomedical Sciences
Created March 2022.
How would you describe the relationship between coaching and feedback?
According to Van der Ridder (2008), feedback in clinical education is “specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance.” Effective feedback describes the observed behavior. Feedback reinforces positive behaviors and identifies areas for improvement. Coaching goes beyond feedback by identifying performance goals in response to feedback and developing plans to achieve them. Coaching is student-centered and individualized. Coaching encompasses a broader set of conversations that include a collaborative discussion of goal setting, prompting of student self-assessment, delivery of specific, descriptive feedback by the clinician, seeking of student perceptions of and reactions to feedback, and joint brainstorming for changes that may be made to improve performance. Coaching facilitates the development of student ability to critique their own performance which in turn allows the student to develop skills supportive of lifelong learning. In this process students develop the skills of self-assessment and self-regulation that are essential for veterinarians.
What is the role of coaching in CBVE?
Implementation of competency-based veterinary education requires a coaching culture to help students achieve the outcomes. CBVE is student-centered and allows the learning experience to be tailored to the student. Deliberate practice under the guidance of an expert coach, as described by Ericsson and others, will enable students to develop expertise. The role of the coach is essential. To implement CBVE, the paradigm needs to shift from assessment of learning to assessment for learning.
What do you consider to be the key features of coaching?
A key component of coaching is development of a relationship between the coach and student. Coaching is most successful when the learner has belief in the abilities and knowledge of the coach and a clear understanding of the coach’s intentions with the knowledge that the coach is working from a position of beneficence. Establishing this relationship is facilitated through dialogue that may include collaborative goal setting and sharing of expectations as they relate to milestones and competencies. A shared mental model of goals and desired outcomes is essential for establishing trust and maintaining learner safety.
According to Fernando (2008), only 50% of feedback encounters in medical education included strategies for how the learner could improve. This emphasizes the need for coaching to include a plan for both how improvement or change will be implemented and when that competency or skill will be observed for additional input. This approach promotes effective coaching strategies and documentation of clear performance improvements in competencies.
In order to establish this coaching relationship and facilitate change with planned follow-up, the common clerkship system employed by many veterinary schools may need to be changed to allow relationship development and observation of students over time. With students spending 2 or 3 weeks on a rotation, it is challenging to develop a trusting relationship and it is difficult to provide feedback over time to make summative assessments regarding progression. Additionally, students may work with multiple clinicians during a rotation and each clinician may have observed the student’s performance only occasionally.
Do characteristics of the student and/or the instructor impact the benefits of feedback?
In order for coaching to have the greatest benefit, students and clinicians have to embrace a growth mindset. Clinicians who embrace a growth mindset are more inclined to embrace assessment for learning as opposed to assessment of learning. Faculty who embrace a growth mindset are more likely to provide feedback and coaching because they view it as providing a growth opportunity for students as compared to the common feeling of delivering bad news when providing a summative assessment. Students and faculty with growth mindsets see mistakes as an opportunity to learn and grow. Students with a growth mindset welcome feedback and may seek it out because they see it as an opportunity to improve. Individuals with fixed mindsets generally avoid feedback and when they receive feedback that is critical, they may give up or be very hard on themselves. Students with a more fixed mindset may avoid challenges because they do not want to look “bad.”
Stage of professional development influences students’ responses to feedback. More junior medical students usually described receiving feedback as a passive experience and preferred to receive positive feedback that reassured them and confirmed they were progressing. More senior medical students described feedback as guiding their professional development and valued informal verbal feedback from senior clinicians as well as from peers and others.
Murdoch-Eaton and Sergeant (2012), reported that more than 95% of medical students consider feedback important and yet only 36% reported knowing where to seek feedback. It is common for students to not recognize when feedback is given. It may be helpful to teach students about the different types and sources of feedback and to label feedback as such when it is provided. Feedback can be normalized as an integral part of clinical training to avoid students reacting negatively and encourage feedback seeking behaviors. If students are exposed to frequent feedback early in their programs, they could be better prepared for the frequent feedback in the clinical environment.
Good communication skills, frequent availability, and content expertise are other features of the coach that positively impact the coaching relationship. Reports from Bok et al., indicate that veterinary students are more likely to seek feedback when they view the faculty member as a good communicator. Crommelinck and Anseel (2013) reported that in medical education, learners were more likely to seek feedback from faculty they identified as having greater expertise and greater accessibility.
How do you transition to a coaching culture in a veterinary teaching hospital?
There are a several perspectives that must be considered to transition from a culture of assessment of learning (evaluation) to assessment for learning (coaching).
The environment and mission of veterinary teaching hospitals (VTHs) must be considered. VTHs are intended to provide a workplace-based experience for veterinary students that will transform them into competent veterinarians. This need to teach is often overshadowed by the mission of the VTH to provide top quality patient care and client service because it is essential that patient care be the highest priority. A shift of clinicians’ frame of reference from providing patient care first and teaching second to teaching being an essential component of excellent patient care facilitates the development of a coaching culture. Faculty are responsible for modeling best practices in the hospital as well as ensuring that veterinary students provide safe and effective patient care. This requires direct observation of student performance and coaching feedback to help the student develop competence. Direct observation is essential for effective coaching. It’s not possible to coach someone on how to golf without directly observing them swinging a golf club. Likewise, veterinary students must be directly observed in the workplace doing the activities of a veterinarian, also known as entrustable professional activities (EPAs). In addition, the AVMA Council on Education requires documentation of direct observation of each student for evaluation of clinical competence.
Meaningful feedback is formulated by comparing these observations to a standard of practice. This requires instructors to be well versed in current standards of practice so that their feedback is accurate. In medical education it has been found that some clinicians may require training to bring their knowledge and skills up to the current standard of care and to improve their observation skills. Student coaching can become an integral part of clinical practice in the teaching hospital by examining work processes and identifying small changes that can be made to allow direct observation of student work and brief, immediate feedback without hampering the work flow.
There is the perception that feedback takes a lot of time, so it is often one of the first things to go when the hospital schedule becomes very busy. However, brief, focused, in-the-moment feedback takes little time and is highly effective. Clinicians can develop the habit of briefly stopping to give verbal feedback which takes only a minute or two. Frequent, short observations are usually better than one long observation and targeted feedback can be provided. It is not necessary to observe the entire patient/client encounter to provide effective coaching feedback. A portion of an EPA, such as obtaining a history, could be directly observed. Many short observations by multiple instructors can provide rich feedback. Providing better feedback to students will improve their skills and improve patient care.
It is not practical for faculty to observe everything that students do, so the entire healthcare team should be trained in best clinical practices in their area of expertise and in how to coach students. If all team members have a coaching mindset, the learning environment will be more supportive and encourage students to stretch themselves by attempting skills they need to learn.
Useful References
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