Clinical education: nursing students’ experiences with multisource feedback using a digital assessment instrument in the emergency medical Service – a qualitative study | BMC Medical Education

The themes, categories and codes were identified through reflexive thematic analysis, supported by representative quotations from students, capturing their diverse perspectives on MSF when utilizing a digital assessment instrument. Three major themes emerged from the analysis of data collected from four student focus groups, with each theme encompassing various categories that reflect the nuanced experiences and insights of the participants.

Each theme is described in detail through its corresponding categories, which provide a deeper understanding of the student’s experiences with the feedback process. These themes, along with their categories, offer a comprehensive overview of how students perceive MSF, highlighting its positive impacts as well as areas requiring improvement. Table 1 presents a summary of the themes and categories that emerged from the qualitative analysis, along with illustrative quotations from both students and faculty/administrators, providing further context. Below, each theme is described in greater detail to enhance the understanding of the findings.

Feedback from sources familiar with the learning outcomes

Students discussed diverse experiences related to feedback from sources familiar with the LOs. These experiences were organized into categories based on the sources of the feedback, resulting in the following three categories: Self-reflection, Feedback from peers, and Feedback from supervisor.

Students generally described the experience of self-reflection as positive. This feedback instigated a personal reflection on the student’s performances. The insights that the students had then facilitated discussions with their supervisors and their peers, leading to constructive feedback from both parties.

“Then I recalled: What did I do regarding the LO? Did I do it well, and what could I have done differently?” (Focus Group 1).

“A bit of self-reflection is good.” (Focus Group 1).

The students described being more critical in their reflections on their own performances compared to other sources like supervisors or peers. Therefore, the discussions with peers and supervisors were crucial to transform self-criticism into constructive feedback. Two student’s comments illustrated this:

“You don’t want to give yourself a seven (using the 1–7 Likert scale), you can always do better.” (Focus Group 4).

“I am so critical towards myself that it becomes straining.” (Focus Group 1).

Overall, the students concluded that self-reflection, combined with supervisory feedback, was beneficial for their learning since it motivated them to reflect on their performances instead of simply performing tasks. The students also concluded that more frequent self-reflection would be beneficial. They suggested that self-reflection could enhance the quality of care they provide and their ongoing development toward becoming RN. This was exemplified by one student saying:

“I believe that if I would have self-reflected more regularly, like every day, at least once a day would have been fun.” (Focus Group 2).

Students described feedback from peers as a positive experience. They noted that such feedback facilitated discussions and encouraged peer dialogue, thereby supporting each other’s learning and development towards becoming RN. Reflecting on their experiences with peer feedback during caregiving encounters, students remarked:

“Feedback from peers was educational.” (Focus Group 1).

“Feedback from peers created discussions.” (Focus Group 4).

“Reflections instigated dialog.” (Focus Group 4).

The students highlighted that feedback from peers fostered a supportive environment, enabling them to assist one another. They discussed that feedback from peers encouraged reflection and cultivated a sense of camaraderie and mutual support. This support was particularly valuable given the recurring sense of vulnerability students often experience during their clinical education. The students said:

“We saw each other’s progression.” (Focus Group 1).

“I could support my peer using the peer-assessments.” (Focus Group 2).

However, the students also discussed the potential challenges of providing feedback to peers who were struggling with their learning progress. This related to the fact that the students worked closely together during their clinical education and criticism could jeopardize the comradery and the team spirit. Furthermore, the students identified that different personal goals during clinical education could be hampering and could provide challenges in giving feedback. The students exemplified this by saying:

“It would probably be hard to provide feedback if someone was performing badly.” (Focus Group 3).

“It would be difficult if the level of ambition differed.” (Focus Group 4).

On the other hand, students discussed the supporting nature of the assessment instrument. Students described that the assessment instrument could be helpful in situations where constructive criticism could be challenging to convey. The assessment instrument provided structure and a sense of objectivity for the peer. The assessment instrument helped make the feedback less dramatic for the receiving party. A student said:

“Couldn’t it be good and nice if you could use the assessment instrument as a tool for giving feedback? Then you don’t need to confront your peer.” (Focus Group 3).

Students regarded feedback from supervisors as essential for their professional development. The feedback provided critical direction, without which they felt disoriented. Additionally, the feedback contributed to students feeling recognized as individuals. The students said:

“You want to know that you’re on the right path.” (Focus Group 4).

“I feel that if I don’t get feedback then I become lost.” (Focus Group 4).

“Feedback is very important for me to feel seen.” (Focus Group 4).

The students also discussed the potential benefits of anonymity in supervisor feedback, suggesting it might lead to less biased feedback. Students discussed that the supervisors might avoid giving negative feedback to avoid confrontation which is exemplified by one student statement:

”Feedback could be done anonymously, then it becomes a fairer assessment.” (Focus Group 2).

Moreover, students expressed a desire for more constructive feedback from their supervisors. The feedback from supervisors was seen as a cornerstone of student education and, thereby, as the most important.

“I would have wished for more, more constructive feedback.” (Focus Group 1).

Feedback from sources unfamiliar with the learning outcomes

Students’ experiences of feedback from sources unfamiliar with the LOs were diverse in nature. These experiences were organized into categories based on the sources of the feedback, resulting in the following two categories: Feedback from patients and Feedback from other care professionals.

Students described difficulties in gathering feedback from patients. Various issues were highlighted, particularly the patients’ inability to provide informed feedback on LOs they had no prior knowledge about. Additionally, patients limited understanding of the educational process made their feedback seem arbitrary. As some students remarked:

“Patients and next of kin are so unknowing of the meaning of the clinical education. The feedback becomes unfunded.” (Focus Group 1).

“We had a discussion with a patient, and he didn’t even understand the meaning of the words.” (Focus Group 2).

”The patients are not familiar with what we students do.” (Focus Group 1).

The students also claimed that patients’ medical and psychological status affected their ability to provide feedback. The students reflected on the fact that they felt that patients tended to focus solely on themselves in their time of need thereby not being able to provide feedback on staff performances. They also claimed complications related to the patient’s age were elderly patients and children struggled with the quantity of the LOs. The students stated:

“It is hard to ask for assessments when someone is filled with anxiety and only wants to be helped.” (Focus Group 2).

Elderly and children primarily. It might be enough with five questions for them.

(Focus Group 2).

The students also described feeling uncomfortable asking patients for feedback. The students also reflected upon prior statements about believing in patients’ medical and psychological status and reasoned that their prejudices might be the real obstacle in asking for feedback.

“For me, it felt hard if it concerned patients and next of kin.” (Asking for feedback).

(Focus Group 1).

“I believe that it is more about me feeling uncomfortable with handing it over to the patient (the assessment instrument). It is more about me than the patient or the instrument.” (Focus Group 1).

Some students also had negative feelings about feedback provided by patients. These concerns were related both to how the feedback was perceived and to potential biases in the feedback. Students discussed that they struggled with accepting negative feedback from patients which was not in line with their reflections on their performances. Students noted that they tended to ask for feedback from patients with a more positive demeanor, which often resulted in receiving more praise than constructive criticism.

“I could not take to me the feedback provided. I knew I did nothing wrong.” (Focus Group 3)

”It naturally happens that patients that respond perhaps are those who are more satisfied patients from the start, so it becomes skewed.” (Focus Group 4).

“As I said, a certain patient group is selected when asking for assessments.” (Focus Group 3).

The students also described positive experiences with feedback from patients. The students recognized that the patient’s perspective of the care provided, and that information could be beneficial for their development. The students also recognized that their own and the supervisor’s reflections on the care provided could dilute the information and skew the perspective.

”It is very valuable to know how you handled the situation.” (Focus Group 1).

“It is good to get insights on the patient perspective.” (Focus Group 3)

“They can provide more details about how they have experienced the encounter instead of the supervisor telling me how the caring encounter was.” (Focus Group 4).

The students expressed generally positive views about other care professional’s feedback. They emphasized the value of receiving insights from diverse perspectives within the healthcare setting, noting the particular importance of feedback from RNs who directly receive handovers. The students also discussed expanding feedback from other care professionals to additional sources due to its invaluable perspective on their performance. The students articulated that:

“The handover needs to be comprehensible for the one who receives it and is supposed to pass it on in the organization wherefore, his or her feedback is super important.” (Focus Group 1).

“It feels superb to get feedback on the handover” (from the receiving RN) (Focus Group 2).

“Additional sources involved in patient care would have been beneficial.” (Focus Group 1).

However, students also identified challenges in receiving feedback from other healthcare professionals, mainly due to workload and timing constraints. The students discussed whether the feedback from a stressed healthcare professional could be overly negative due to the negative attitude of the student in question. They also discussed that the feedback could be given in a sloppy matter due to the workload and the unwillingness to give feedback. They highlighted several issues related to this.

“There was no time for that.” (Focus Group 1).

“They are already signing because it takes longer for us.” (Focus Group 2)

“Everyone is sitting inline, waiting to give their handover rapport and it doesn’t feel like the right time.” (Focus Group 4).

General perceptions of multisource feedback in emergency medical service

The students also discussed the contextual influence of MSF and MSF in general in relation to their learning progress. This resulted in two categories: Context and Multisource feedback in the EMS.

During the focus groups, students highlighted several contextual challenges they faced regarding MSF during their clinical placements, comparing their experiences across different clinical environments. They noted specific obstacles in the EMS with the high stress setting and patients with medical and nursing needs that those students seldom had encountered previously in their education. The inherently stressful nature of working in ambulances and the difficulty in finding appropriate times to provide feedback were significant issues. The students said:

“It is very stressful in the ambulance.” (Focus Group 4).

“Finding the right time for feedback is a challenge.” (Focus Group 2).

“It becomes a discussion for like 15 minutes or so for every patient and that kind of time doesn’t exist.” (Focus Group 1).

The students suggested that wards within the hospital might be more conducive to MSF. They emphasized the advantages of longer patient stays, which facilitate the development of relationships between students and patients. This setting also allows the possibility of leaving the assessment instruments with patients and returning later, giving patients more time to provide helpful feedback. The students commented:

“It would be easier, definitely.” (In a nursing department) (Focus groups 2 & 3).

“You see the patient more frequently over a longer period of time.” (Focus Group 4).

“You can leave it and come back at a later time.” (The assessment instrument) (Focus group 1).

When discussing the pedagogical method, students generally regarded MSF positively. They appreciated the diverse perspectives, noting that it enriched the quality of team discussions and interactions with their supervisor. Students recognized that MSF offered more comprehensive and fair feedback, as it incorporated documented assessments from multiple sources. This multifaceted feedback provided a well-rounded view of their performance, which was valuable both for constructive discussions and for the grading process.

“Because we had different supervisors, it felt like it gave a fair picture.” (Focus Group 2)

“This instrument would be amazing to show at the assessment conference with all the different assessments. We could say, “Look, this is how the student has developed and progressed, with all these measurements and assessments.” (Focus Group 4).

“Many people have been involved in this, and the evaluations are interconnected.” (Focus Group 4).