EMS Feedback

Cite this article as:
Andrew Patton and Andy O'Toole. EMS Feedback, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29849

Prehospital practitioners have an ever-expanding role in managing the acutely unwell and injured patient. Despite this large contribution to patient care, the majority of practitioners find it very challenging to followup or get feedback on their management of the patient.

The recent publication of the NEMSMA position paper regarding bi-directional information sharing between hospitals and EMS agencies sparked debate on Twitter about the challenges of EMS Feedback.

Gunderson, M.R., Florin, A., Price, M. and Reed, J., 2020. NEMSMA Position Statement and White Paper: Process and Outcomes Data Sharing between EMS and Receiving Hospitals. Prehospital Emergency Care, pp.1-7.

What was the paper about?

The NEMSMA Position statement and White Paper focuses on the bi-directional sharing of data between EMS agencies and receiving hospitals. The authors looked at the challenges EMS agencies face getting feedback data regarding patient outcomes, propose best practices for bi-directional data sharing and explore the current barriers to data exchange. 

The paper highlights the importance of receiving feedback and patient outcome data for quality assurance and improvement (QA/QI). Among other things, feedback is necessary for EMS providers to determine if clinical diagnoses in the field were correct, if pre-arrival notifications were effective and if the destination choice was appropriate. 

The authors surmise that with confusing and complicated healthcare law, hospitals can be reluctant to “share information due to consequences of unintentional violations” of healthcare law, and fears of liability, many of which are misconceptions.

They report that…

“Many of the commonly held legal concerns preventing data exchange are misunderstandings and unfounded fears. While all regulations and laws need to be adequately addressed, legal issues should not preclude properly conducted sharing of electronic health records for quality improvement.”

Technology also creates a number of barriers to data sharing, in particular poor interoperability between EMS electronic patient care records (ePCR) and hospital electronic healthcare records (EHR). The absence of a universal patient identification value is another significant obstacle.   

The authors reference information blocking and market competition between hospitals as two of the big political and economic barriers which can be among the most challenging to overcome. 

They conclude by recommending a collaborative effort between EMS agencies and hospitals to develop and implement bilateral data exchange policies which would benefit all stakeholders. 

This paper focuses mainly on data sharing at an organisational level, it is very relevant to the difficulties faced by individual pre-hospital practitioners trying to follow-up on patients they treat at a local level. 

Why is this so important?

As discussed in the paper, feedback is an important part of quality improvement. For individual practitioners, feedback is a vital part of the learning cycle. Feedback is essential for us to learn from our mistakes, and to improve our practice.  To improve any performance, it is necessary to measure it. A practitioner that never follows up on a patient’s outcome will be left assuming that their treatment for the presenting complaint was accurate and warranted. They will likely continue to treat the same presentation in the same way in the future because their experience has never been challenged by facts that could have been discovered during patient follow up. 

Without feedback we could be unconsciously incompetent… We don’t know what we don’t know!

What’s the difficulty?

On an individual level, obtaining feedback and patient follow-up is challenging for EMS crews for a variety of reasons. In a local survey of 98 prehospital practitioners in Dublin, Ireland, only 21% of practitioners reported being able to follow-up interesting cases.

With dynamic deployment of EMS Resources, crews might transport a patient to a hospital and not return to that same hospital during their shift. If a crew does manage to find an opportunity to call back to the hospital, frequently the diagnostic work-up may be incomplete, and a working diagnosis still unclear. EDs are busy environments and, understandably, some practitioners may feel uncomfortable stopping a doctor or nurse to follow-up on a previous patient.

Calling back a few days later has its own complications; often there will be different staff working in the department who may not have been involved in the patient’s care. This method may work for the high-acuity resus presentations, but that ‘child with shortness of breath’ whose physical exam you were unsure of, or the child with a seizure who had a subtle weakness… the chances of the Emergency Department (ED) staff remembering their diagnosis or outcome is slim! 

Phoning the ED or ward is a route explored by many practitioners, but is fraught with increasing difficulty due to reluctance of staff to give out patient information over the phone fearing confidentiality issues. 

So how do we address this challenge?

Focusing specifically on providing feedback to individual pre-hospital practitioners, there are multiple potential ways to provide prehospital practitioners with follow-up information and feedback,  but you need to consider what system will work best for your individual department, ensuring patient confidentiality and data security.

The pre-hospital postbox

St. Vincent’s University Hospital is a tertiary referral hospital in Dublin, Ireland with approximately 60,000 annual attendances. Inspired by Linda Dykes and her team’s PHEM postbox at Ysbyty Gwynedd Emergency Department in Bangor, Wales, we set-up the Pre-Hospital Post Box in St. Vincent’s University Hospital Emergency Department in August 2017. 

We engaged local prehospital clinicians and ED consultants to develop an SOP. A postbox was built and mounted by the carpentry department. Using a template from Bangor, a feedback request form was developed.  Finally, the service was advertised in the emergency department, local Ambulance and Fire Stations and we were open for business. 

Prehospital clinicians seeking feedback on a case complete a form and place it in the post-box. The case notes are reviewed by an EM doctor and feedback is provided by phone call. 

To ensure patient confidentiality, feedback is only provided to practitioners directly involved with the patient care. A triple-check procedure is used to confirm this. The practitioner’s pin number on the request form is verified on the Pre-Hospital Emergency Care Council (PHECC) register and against the patient care record. The listed phone number is also verified through practitioners known to us or the local Ambulance Officer. 

Other hospitals use systems providing feedback via encrypted email accounts or posted letters.We elected to use a phone call system, the primary reason was the anecdotal reports that many of our pre-hospital staff don’t have easy access to work email accounts. We also anticipated that a phone call would be more likely to facilitate a case discussion and allow paramedics to ask questions that might arise during the discussion. 

Challenges with this system?

Providing feedback to prehospital practitioners is a very time-consuming and labour intensive job, particularly in hospital systems where the majority of clinical documentation is still paper-based. In our own system, where handwritten ED notes are scanned, radiology, labs and discharge letters are available on-line, and in-patient notes are handwritten physical charts – we’ve found the average time required to collate details for the feedback request is just 9 minutes, with a feedback phone call averaging 5 minutes per call.

To successfully upscale this would require a team of doctors or a rota based system with allocated non-clinical time to answer requests. Alternatively a digital solution allowing paramedics to access the data themselves, or facilitating the physician managing the case to reply directly would make it more feasible but may generate further challenges. 

The ideal, as discussed in the NEMSMA paper, would be an organisational process, with the automatic provision of discharge summaries and test results by hospitals to EMS agencies which would provide useful organisational data, and subsequent feedback to individual EMS practitioners.

GDPR / Data Protection Considerations

Patient confidentiality and data protection are of utmost importance in an EMS Feedback System. The system implemented needs to have robust mechanisms, such as our triple-check, to ensure that feedback is only provided to healthcare professionals directly involved in the patient’s care. 

It is also important that it is compliant with data protection legislation in your locality, such as General Data Protection Regulations (GDPR) introduced in Europe in 2018.  Our EMS feedback system is an important mechanism for us to review the care and treatment provided to patients and allows us to assist pre-hospital practitioners in evaluating and improving the safety of our pre-hospital services, which is provided for in the “HSE Privacy Notice – Patients & Service Users”

Providing EMS Feedback, in its current form, is a labour intensive process but we believe it is a worthwhile initiative. It is greatly appreciated by Pre-Hospital Practitioners and it enables them to enhance their diagnostic performance and develop their clinical practice.

If you’d like to find out more about how to set up a Pre-Hospital Post Box in your ED, have a look at these resources…

Attachments

References

Patton A, Menzies D. Feedback for pre-hospital practitioners: is there an appetite? Poster session presented at: 2017 Annual Scientific Meeting of the Irish Association for Emergency Medicine; 2017 Oct 19-20; Galway, Ireland.  

Gunderson MR ,Florin A , Price M & Reed J.(2020): NEMSMA Position Statement and White Paper: Process and Outcomes DataSharing between EMS and Receiving Hospitals, Prehospital Emergency Care, https://doi.org/10.1080/10903127.2020.1792017 

Croskerry P. The feedback sanction. Acad Emerg Med. 2000;7:1232-8.

Jenkinson E, Hayman T, Bleetman A. Clinical feedback to ambulance crews: supporting professional development. Emerg Med J. 2009;26:309.

Patton A, Menzies D. Case feedback requests from pre-hospital practitioners – what do they want to know? Meeting Abstracts: London Trauma Conference, London Cardiac Arrest Symposium, London Pre-hospital Care Conference 2018. Scand J Trauma Resusc Emerg Med 27, 66 (2019). https://doi.org/10.1186/s13049-019-0639-x  

Patton A, Menzies D. Feedback for pre-hospital practitioners – a quality improvement initiative. Meeting Abstracts: London Trauma Conference, London Cardiac Arrest Symposium, London Pre-hospital Care Conference 2018. Scand J Trauma Resusc Emerg Med 27, 66 (2019). https://doi.org/10.1186/s13049-019-0639-x   

O’Sullivan J. HSE Privacy Notice – Patients & Service Users v1.2.  2020 Feb, Accessed on-line: https://www.hse.ie/eng/gdpr/hse-data-protection-policy/hse-privacynotice-service-users.pdf 


Safety Netting

Cite this article as:
Carl van Heyningen. Safety Netting, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28803

Safety netting is a cornerstone of paediatric practice. 

Children are a vulnerable group. Their condition can deteriorate and improve rapidly. Uncertainty is inherent in paediatric emergency medicine. From the child with a fever to the infant with vomiting, it is up to us to safeguard children from harm.  

Of course, we can’t admit every child to the hospital. Nor should we. The vast majority of patients in A&E return home with reassurance. Easy right? Reassure. Give advice. Send home. Simple?

You’re at the end of a busy shift and you have a train to catch. You’ve put in blood, sweat, and tears and feel happy your last patient has a simple throat infection. You advise fluids, paracetamol for symptoms of headache and neck pain and to come back if worried. The mother is anxious, you give them a leaflet on fever and rush out the door. 

Typically, our focus is on the front door of care not the exit. Discharge care is often overlooked. Even in the best of circumstances, we are under pressure to maintain patient flow especially as our emergency departments begin to become busy again. 

The next morning, coffee in hand, you walk in the department and hear the words that strike fear into the hearts of all that hear them… 

“Do you remember that child you saw yesterday? They’re being admitted to intensive care, it looks like meningitis.”

What could you have done differently? More tests? Not necessarily needed, no? More time? They had been observed and appeared well for several hours. Senior review? You’d seen them with the Consultant and agreed on the diagnosis. Then what? 

Safety netting

Why is it important? 

Acute illness remains one of the most important causes of childhood mortality in the UK. Early illness is notoriously non-specific. Take meningitis. In only half of cases, diagnosis is made at the first presentation. So what do we do? We must educate parents about uncertainty. Discuss the potential for deterioration. Explain the importance of seeking further help if necessary. We must safety net. 

What is it?

The term was first formally described in 1987. Today, it has come to mean “advice about what to do and what to look out for to empower parents and carers to seek help if the child’s condition deteriorates further or if they need more support.”  

What else should it cover? 

In addition to the above, it is critical to cover how they should seek help, what they should expect ahead (the disease course) and when to become worried.

How should it be done? 

Whilst verbal and written formats exemplify current practice, ranging from information leaflets to printed discharge letters, audiovisual and online resources are growing in abundance. Families report wanting this varied range of approaches.

Let’s consider the options. 

Face to Face – individualized, personal but highly variable and time-dependent

TOP TIP – be adaptable (don’t just simply recite the same information each time)

Social, educational, and cultural differences may all necessitate adapting your usual spiel in order to truly achieve understanding. Remember, the parents are in an unfamiliar, often noisy, and stressful environment in addition to feeling worried about their child. Expect them to be distracted a little. 

Leaflets – standardised, quality assured but not necessarily up to date and potentially bland and uninteresting. 

TOP TIP – use leaflets to re-enforce verbal information

When taken home written materials can often act as an aide memoire.  

Audio-visual – engaging and memorable with the potential to overcome literacy and language barriers if well designed, though resource intensive and expensive upfront   

Internet, social media, websites, apps – there are many innovative methods of connecting families with health information. Our responsibility is thus to navigate the clutter, signpost reliable resources, dispel myths and thus champion true evidence based materials. 

TOP TIP – keep the message simple, it can be easy to overwhelm parents with information. 

Remember, many parents may not wish to go on the internet. A few may even not have access to it. 

Why tailor the information? 

As ever, before talking we must first listen. For example, one interview based study found a mother worrying about “their child with cough dying at night through choking on phlegm.” If we do not listen to such fears how can we expect our own advice to be heard. 

Parental priorities

Parents priorities include… 

Emotional distress (addressing this)

Physical symptoms (addressing these)

Information (providing this, particularly reassurance, diagnosis and explanation)

Care (basic care, including food drink and friendliness)

Closure (finding out what’s wrong and, where possible, going home)

An awareness of these priorities can inform our conversations, helping us to better look after our patients from their perspective.

Ok, but what is the reality?

“You don’t actually know how much of that leaflet they’re gonna actually understand, take in, comprehend… going through things step by step, listening, understanding and explaining, I think is more beneficial” (Paediatric ED doctor). 

“It’s very difficult to know ‘cause often they’ll nod their heads and say “yes I understand everything you say” and walk off and they might have no idea what we’ve just said”  (ED staff nurse). 

“If you’ve got a sick child at home and they’re moaning at you, you haven’t got the time to go on the internet… you’ve got a child hanging off your leg going, “Mummy I feel poorly, mummy I want this, mummy I want that”” (Mother).

“My doctor did give like an information leaflet… and I did read through it, because when you’ve got a sheet at least you can find time to do that” (Mother).

So how can we do it best?

After reviewing the literature and FOAMed (see further resources) here are my top tips for giving the very best safety netting advice, enjoy! 

  • Sit down – it has been shown to increase the perception of empathy 
  • Verbalize back concerns – be explicit important conditions have been excluded 
  • Explain things – share reasoning, show your process 
  • Highlight red flags – signs that necessitate reattendance
  • Be specific – ‘If x happens, do y’
  • Reinforce – provide written leaflets
  • Avoid criticism, foster understanding – put yourself in their shoes 
  • Document advice – yes, write down what you said 

And as with all good communication, ensure a quiet, private area and avoid using jargon. 

Finally, directly ask if parents understand and are happy. Don’t assume they are. 

Here is one good example to get you started… 

“…your little guy is likely to continue to have vomiting and diarrhoea. If he remains well in himself, is drinking the amount of fluid we have discussed and is having wet nappies then he is unlikely to become dehydrated. If, however, he becomes drowsy, develops a fever or fails to stay hydrated please call this number and come back to us.” 

We must stop thinking of reattendance as a failure – patients do get worse and some need to return. 

Good quality safety netting means both you and your patients can get a better nights sleep. 

References

Gill P, Goldacre M, Mannt D, Heneghan C, Thomson A, Seagroatt V and Harnden A (2013) ‘Increase in emergency admissions to hospital for children aged under 15 in England, 1999–2010: national database analysis’, Archives of Disease in Childhood 98, 328–34.

Wolfe I, Cass H, Thompson MJ, Craft A, Peile E, Wiegersma PA, Janson S, Chambers T, McKee M: Improving child health services in the UK: insights from Europe and their implications for the NHS reforms. Bmj 2011, 342:d1277.2. 

Thompson MJ, Ninis N, Perera R, Mayon-White R, Phillips C, Bailey L, Harnden A, Mant D, Levin M: Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006, 367(9508):397–403.3. 

Neighbour R. The inner consultation. Lancaster: MTP Press, 1987.

NICE guideline [NG143], Fever in under 5s: assessment and initial management, November 2019

Available at https://www.nice.org.uk/Guidance/Ng143/evidence

Almond S, Mant D, Thompson M: Diagnostic safety-netting. The British journal of general practice: the journal of the Royal College of General Practitioners 2009, 59(568):872–874

Jones CH, Neill S, Lakhanpaul M, et al. Information needs of parents for acute childhood illness: determining what, how, where and when of safety netting using a qualitative exploration with parents and clinicians. BMJ Open 2014;4:e003874.

Neill SJ, Jones CH, Lakhanpaul M, et al. Parent’s information seeking in acute childhood illness: what helps and what hinders decision making? Health Expect 2015;18:3044–56. 

Austin PE, Matlack R, Dunn KA, et al. Discharge instructions: do illustrations help our patients understand them? Ann Emerg Med 1995;25:317–20.

Scullard P, Peacock C, Davies P. Googling children’s health: reliability of medical advice on the internet. Arch Dis Child 2010;95:580–2.

Mackert M, Kahlor L, Tyler D, et al. Designing e-health interventions for low-health-literate culturally diverse parents: addressing the obesity epidemic. Telemed J E Health 2009;15:672–7.

Knight K, van Leeuwen DM, Roland D, et al. YouTube: are parent-uploaded videos of their unwell children a useful source of medical information for other parents? Arch Dis Child 2017;102:910–4.

CS Cornford, M Morgan, L Risdale, Why do Mothers Consult when their Children Cough?, Family Practice, Volume 10, Issue 2, July 1993, Pages 193–196

Body R, Kaide E, Kendal S, et al. Not all suffering is pain: sources of patients’ suffering in the emergency department call for improvements in communication from practitioners, Emergency Medicine Journal 2015;32:15-20.

(15) Jones, C.H., Neill, S., Lakhanpaul, M. et al. The safety netting behaviour of first contact clinicians: a qualitative study. BMC Fam Pract 14, 140 (2013)

Jones, C.H.D., Neill, S., Lakhanpaul, M., Roland, D., Singlehurst-Mooney, H. and Thompson, M., (2014) Information needs of parents for acute childhood illness: determining ‘what, how, where and when’ of safety netting using a qualitative exploration with parents and clinicians. BMJ Open 4 (1). 

Further resources

RCPCH (2015) Facing the Future: Standards for acute general paediatric services. RCPCH.

RCPCH Safe System Framework, resources accessed 19th November 2019,  https://www.rcpch.ac.uk/resources/safe-system-framework-children-risk-deterioration

Dr. Natalie May, MBChB, MPHe, MSc, PGCert Medical Education, FRCEM, FACEM, #CommunicatED 1: Discharge & Safety Netting in ED, available at https://www.stemlynsblog.org/communicated-discharge-safety-netting/

Bruera, Eduardo & Palmer, J Lynn & Pace, Ellen & Zhang, Karen & Willey, Jie & Strasser, Florian & Bennett, Michael. (2007). A randomized, controlled trial of physician posture when breaking bad news to cancer patients. Palliative medicine. 21. 501-5.

Sarah Jarvis, Medico-legal adviser

BSc MBBS MRCGP, Playing it safe – safety netting advice, available at https://mdujournal.themdu.com/issue-archive/issue-4/playing-it-safe—safety-netting-advice

Damian Roland, BMedSci (Hons) MBBS MRCPCH, PhD, TIGHTEN UP YOUR SAFETY NET #WILTW, available at 

https://rolobotrambles.com/tightenyoursafetynet/

Safety netting – a guide for professionals and parents of sick kids from GP Paedtips

Shame. How it affects patients and their relationships with health care professionals. https://abetternhs.wordpress.com/2012/11/16/shame/ 

The Medicines Handbook: Simon Craig at DFTB18

Cite this article as:
Team DFTB. The Medicines Handbook: Simon Craig at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20590

Ask any paediatrician what the hardest, tricksiest procedure that you might ever have to perform and they would all be in agreement – calculating drug doses in the middle of a paediatric resuscitation. In this talk Simon Craig, from Monash, takes us through the how we can do better than scratching out rough calculations on the whiteboard at 6am. He asked the key question…

 

 

 

 

 

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

 

*Lori was once one of Andy Tagg’s trainees but he is quick to point out that none of the situations depicted are about him.

 

Mentoring in Medicine: Melanie Rule at DFTB18

Cite this article as:
Team DFTB. Mentoring in Medicine: Melanie Rule at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20557

Mel Rule is one of the founding members of the extraordinary WRaPEM group. They are a group of passionate educators and clinicians waim to bring back Wellness, Resilience and Performance coaching for the everyday doctor.

Giving Feedback: Lori Chait at DFTB18

Cite this article as:
Team DFTB. Giving Feedback: Lori Chait at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20517

When we learn about feedback it is often from the side of the wise expert, the person giving it. Whilst they might be very good at what they do it is worth considering how the person on the receiving end feels. In this talk from 2018 Lori Chait, a paediatric trainee*, reflects on what it is like to be on the receiving end and how we might do a better job.

 

 

 

 

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

 

*Lori was once one of Andy Tagg’s trainees but he is quick to point out that none of the situations depicted are about him.

 

Giving feedback

Cite this article as:
Tessa Davis. Giving feedback, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11625

Yesterday, you heard one of your junior doctors, Jessica, berating at a colleague at work. It was a busy shift, and she was very stressed and under a lot of pressure. A 7 month old baby presented with bronchiolitis and her mother was struggling to manage at home. Jessica wanted to admit the patient to the ward, but the paediatric registrar on call did not feel admission was required. This interaction escalated and Jessica ended up being aggressive during the referral.

As a consultant, you will like have mentees to supervise. As registrars, we work closely with other, more junior, doctors. Whilst rocking the resus room is part of being a good doctor, actually being able to give feedback constructively and sensitively to our juniors is also a crucial part of being great at our jobs.

The aim of the feedback is to improve the mentee’s performance, not to decimate their confidence. They should go away feeling like they have a plan and are motivated to move forward. Here are our top ten tips for delivering your feedback well.

 

1: Introduce the conversation

“Jessica, do you have a few minutes, I’d like to have a chat to you”

That part seems easy enough. Jessica’s heart may be sinking as she wracks her brain for what might be coming. But you have made her aware that feedback is on the cards.

 

2: Be timely

We learn best through recency, and so feedback is better received closer to the incident. Getting feedback four months later isn’t that helpful. The exception to this is if it is highly emotional or highly charged. In that case it may be best to wait until you cool down.

In Jessica’s case, the incident happened yesterday, so the timing is good.

 

3: Do it in private…

Make sure you have a safe place and won’t be interrupted (particularly when sharing an office). It is humiliating to be criticised in front of your coworkers.

Bring Jessica into your office and make sure your colleagues know not to interrupt. Do not deliver the feedback to her in front of the rest of the department.

 

4: ….Or do it in public

Not all feedback is negative, although the most difficult types usually are. When praise is due, it should be heaped on people in public. Show your employees that you value their achievements. See Adrian Plunkett’s Excellence Reporting as a great example of this (which we have recently implemented in my own hospital ED).

 

5: Be specific

Stick to facts and give examples, and try not to exaggerate “all” or “never”.

Rather than ‘you tend to be rude to your colleagues in other departments” you could say “I have received feedback from an incident yesterday where you spoke aggressively and inappropriately to the paediatric registrar on call.”

State the impact of that behaviour “When you are referring patients, I want the receiving team to realise what a compassionate and competent doctor you are, and not to be distracted by you being aggressive during the conversation”.

 

6: Ask for their reaction

“Jessica, what are your thoughts on this?”

You need to give them a right to reply – is this a fair representation of what happened?

Expect defensiveness! Any normal person will feel affronted when given negative feedback by someone senior to them. They may deny, cry, or simply become enraged. Any of these is a completely normal response. And importantly, remember that there is no right time to give negative feedback. If Jessica gets angry, that is not because you didn’t pick the appropriate moment, it’s because it’s a shameful, embarrassing, awkward experience for her. It’s fine for her to get upset or defensive.

 

7: Provide suggestions

Consider SMART or GROW as frameworks for providing improvement suggestions. Focus on behaviours that can be changed, not personality traits.

“Jessica, can I make a suggestion? Next time you are a referring a patient, try to push all the other stressors going on in the department out of your mind. Focus on the fact that both you, and the receiving doctor have the patient’s best interest at heart. And try to see where they are coming from. Let’s meet again in two weeks to see how things are going.”

 

8: Be sensitive

Don’t be mean-spirited. You can be tough, but do not be mean. Telling someone they are “stupid”, “rude”, or “unprofessional” is not helpful.

The feedback isn’t about you making your mentee feel rubbish, it’s supposed to be for their benefit. If they feel hugely awkward or are made to feel stupid, then they are not going to be able to move constructively forward.

The feedback is for the recipient, not for you, so be sensitive to how your message comes across.

“Thanks for having this conversation with me, I know it was awkward for both of us”.

 

9: Keep it short

It does not take 20 minutes to provide negative feedback. The whole conversation can be tied up in 4-5 minutes. The truth is, Jessica just wants to get out of there and spend some time thinking about what you said/sticking pins in your voodoo doll. You need to let her do this without holding her hostage in your office.

 

10: Reflect afterwards

Although the focus of this feedback was for Jessica, you should take time to reflect on your feedback performance. Did it go as planned? Consider what would you do differently next time.

 

Jessica leaves your office with a flushed face. She is embarrassed, but she knew at the time that she had let the pressures of the department get the better of her. She can do better and will make sure her next referral is dealt with more appropriately so that at your next feedback meeting, things will be more positive.