Mastering Management in Healthcare: Improve your feedback technique

From Radcliffe Publishing

Introduction

In this issue of Mastering Management in Healthcare, it looks at the second of two areas that tend to provoke anxiety in managers old and new – giving feedback to staff and colleagues.

It is worth noting that most of us actually want to know how we are doing, and we look for opportunities to have our work recognised. As long as the process is handled with respect and dignity we don’t even seem to mind being told where we might need to improve. However, recent research shows that of the 77% of NHS staff in England who have access to appraisal, just over a third of those feel it is well structured and leaves them feeling valued(1). Judging by this, there still seems to be a barrier to giving good feedback.

Barriers to giving good feedback

Through our Vital Signs management programmes in Wales over recent years we hear that many managers do give regular praise to their staff, but this can often be of the end of shift – ‘you’ve all done really well today, thank you everyone’ – variety; really important but not sufficient. Managers also report that when tackling staff about poor performance or a lack of engagement, the conversation can easily slide into a self-perpetuating parent/child situation.

By this we mean, if the person starting the feedback conversation comes across (however unwittingly) in a ‘I know best/I’m the boss/you had better listen/what’s wrong with you?’ parental manner, it is likely that the other person will unthinkingly respond with a childlike stance – ‘it’s not my fault, you are picking on me, why do you only talk to me when I’ve done something wrong?’ etc. In the heat of the moment, it is all too easy for the first person to then simply dig in, become even more parental in tone and words, and the self-perpetuating loop is now formed. Each person’s behaviour feeds the other’s response to the point where the original reason for the conversation became irrelevant some time ago. In such situations, if one party changes to a more adult (collaborative and understanding) mindset and we find that, over time, the other person will then also move to an adult stance.

For more information on this behavioural loop and ways to break the cycle, refer to Eric Berne’s work on Transactional Analysis (2), or contact us for a user-friendly summary handout.

Other barriers to effective feedback seem to include:

  • a natural human anxiety about upsetting another person
  • fear of having ones own faults picked upon in return
  • worrying about the issue becoming personal, and
  • trying to get the balance right between praising and correcting

These barriers exist for a reason and so our advice is based on how to work with them, not deny them or see them as evidence of weak management.

Five types of feedback style

The humanist and writer on client centred therapy, Carl Rogers(3) identified five broad types of feedback style – Evaluative, Interpretive, Supportive, Probing, and Understanding – and suggested that we naturally tend to use some more than others.

Evaluative feedback makes a judgment about the other person as a whole – ‘You are kind/you are rude‘ – (evaluating worth or goodness), or a specific action – ‘You really helped me today/you were impatient with that relative‘ – (evaluating appropriateness in a given situation).

Interpretive feedback involves testing your understanding of what has been said by analysing and paraphrasing back to the other person what you think has been said. This can be followed by a question to allow the other person to agree with your interpretation or offer a correction. An example might be ‘You seem to be highly strung today and perhaps not just because of the workload. Is that how you see it?

With Supportive feedback, you seek to lift the other person in some way, perhaps by giving a positive statement accompanied by an exhortation to keep improving. ‘Your handling of bereaved relatives is really coming along – but you might want to offer a quiet room a little earlier in the conversation’, would be an example of supportive feedback.

Probing feedback seeks to find more information by asking deeper questions that seek specific information. This can then lead onto other forms of feedback but it might sometimes be a precursor to problem solving or suggested ways forward. An example might be ‘Tell me more about that altercation with Dr X. Why did you raise your voice and what did you hope to achieve?

With Understanding feedback, you are seeking to understand not just what was said, but also the whole person. The questions not only show that you are listening to the inner person, but also that you truly understand. ‘I can see that this is really upsetting you, do you want to talk it through with someone?

None of these general styles or approaches are automatically right or wrong, but different situations may call for different approaches and it is important to make sure you are choosing a feedback style that is likely to meet the needs of the other person, not just your own preferences.

Best practice

Because many managers spend their working day fixing problems and then moving on swiftly to the next issue, it is easy to see a feedback opportunity as simply another problem to solve. This can lead to a ‘well, this is what you are doing wrong and this is how to put it right’ approach. While quick and easy, this is hardly likely to meet the learning needs of the other person. Indeed it may, over time, create a dependency culture where staff are effectively being trained to bring all problems to the manager rather than attempt to solve them locally. If you feel overloaded by your staff constantly bringing you their problems or not changing their behaviour until told directly by you how to do so, then take a moment to reflect on whether your feedback style may be contributing to that pressure.

Whatever your default style or styles, here are some good feedback practices that satisfy those two important criteria:

  • Meeting the needs of the other person
  • Maintaining an adult-to-adult relationship

Be DESCRIPTIVE rather than evaluative. By describing one’s own reactions to someone’s behaviour, it leaves the individual free to use it or not as he/she sees fit. By avoiding evaluative language, there is less need for the individual to react defensively. You are effectively holding a mirror to the other person (a bit like replaying a video of the event) and most people are more prepared to evaluate themselves quite honestly if the other person simply gives them a neutral opportunity. An example would be ‘when you were chairing that meeting and I tried to make a point on item 3, you interrupted me several times and I felt undervalued’. Note that I am describing the behaviour but owning my emotions. It is difficult for the other person to argue with either aspect, whereas saying ‘you damaged my confidence’ would simply invite an argument.

Be SPECIFIC rather than general. To be told that one is ‘dominating’ will probably not be as useful as to be told that ‘when we decided that issue, you did not appear to listen to what others said and I felt forced to accept your arguments or face attack from you‘. The specificity of the feedback helps contain the discussion and so prevent it becoming a judgement on the whole person.

Be CONSIDERED. Take into account the needs of both the receiver and giver of feedback. Feedback can be destructive when it serves only our own needs and fails to consider the needs of the person on the receiving end. Tearing someone off a strip may make you feel better (briefly), but is unlikely to resolve any underlying issue. Find out over time how this person responds best to feedback and continue to use that approach.

DIRECT your feedback towards behaviour that the receiver can do something about. Frustration is only increased when a person is reminded of some shortcoming over which he or she has no control. A colleague of ours was once told that he was too tall! It might have been more effective to have asked him to reflect on how he might occasionally intimidate people if he stood too close, and to be aware of others’ personal space.

Give SOLICITED rather than imposed feedback. If you create the right environment and culture in your team through your approach to appraisal and actively seeking feedback from your colleagues, you will find that staff will be more willing to ask for feedback. When the receiver has come up with the question the resultant feedback is likely to have more impact.

Make the feedback WELL TIMED. In general, feedback is most useful at the earliest opportunity after the given behaviour (depending, of course, on the person’s readiness to hear it, support available from others etc.). Don’t store up feedback issues until weeks or even months after the event, as this can create the space for an inconclusive argument and damage respect for your management approach.

CHECK your feedback to ensure shared clarity. One way of doing this is to have the receiver try to rephrase the feedback they have received to see if it corresponds to what the sender had in mind.

We should stress that nothing in this e-zine should replace or compromise any policies and procedures your employer has in place for addressing capability, disciplinary matters or grievances. However, for day to day relationships with your staff, whether dealing with fulsome praise or pointing out room for improvement, these approaches to feedback will help to create a developmental culture in your team.

References and further reading

(1) 2010 NHS Staff Survey – summary available via http://www.nhsemployers.org/EMPLOYMENTPOLICYANDPRACTICE/STAFF-ENGAGEMENT/NHS STAFF SURVEY/Pages/NHS-Staff-Survey.aspx

(2) Berne. E., Games People Play: the Psychology of Human Relations; 1964 (1978 reprint, Grove Press, ISBN 0-345-17046-6)

(3) Rogers, Carl R, Client-centered therapy; its current practice, implications, and theory. 1951: Oxford, England Houghton Mifflin

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