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Positive feedback focuses on accomplishments of learners, validates good performance, and provides motivation for commitment to further learning. Novices want positive reinforcement of their commitment. Positive feedback reinforces the efforts of persons who are farther from their goals.

Negative feedback focuses on the rate of progress of learners toward achieving competency. Experts already committed to their profession seek negative feedback on deficiencies to improve performance further. Negative feedback provides a means for realizing when and where more effort is needed. Negative feedback reinforces the efforts of persons who are closer to their goals.

Who is a novice, and who is an expert? For students in the health professions, those categories are fluid. Students gaining admission to professional schools got there by achieving some expertise through a long educational process. They attained a fund of knowledge and demonstrated ability to use it. However, they are now novices at their chosen profession.

In the health professions, novices and experts are evaluated on different scales. The assessments become more difficult with advancement through training programs. Therefore, the feedback given in professional schools assumes some degree of expertise at all levels, but the level of expectations and expertise always increases. Though there may be more positive feedback to enhance motivation at early stages of career development, some negative feedback is always needed for performance improvement.

There is bias towards avoidance of negative feedback, both by superiors (instructors) and subordinates (learners), due to potentially unpleasant reactions. Self-appraisals of learners tend to be higher than actual ratings by instructors, and so evaluations with dissonance between expectations and actual feedback provide an initial feeling of disappointment. If this invokes a defensive attitude, then avoidance of negative feedback is reinforced, and the feedback ratings may become subsequently inflated.

One technique for reducing the emotional responses of both instructor and learner to negative feedback is the 'feedback sandwich'. One begins with a positive comment regarding performance, followed by the negative feedback, then ends with a positive comment.

Persons motivated to achieve expertise realize that negative feedback offers a means for further advancement for success, while positive feedback just tells them what they already know. They are not discouraged by negative feedback, but use it to improve their performance.

Learners new to a training program may take negative feedback as a personal attack. Remember that it is your work that is being critically assessed, not you as a person. Giving feedback takes effort, and that effort reflects a level of care and concern by instructors for their learners. Instructors who want their learners to develop and succeed will provide both positive and negative feedback.

Learners need to receive feedback by listening to what is being said and acting upon it. If you do not agree at first, at least consider the information provided. Take it or leave it, but first consider what was said and why. Negative feedback provides an opportunity to demonstrate maturity, cooperation, ability to adjust, and capability for growth. Use it to clarify expectations and goals. Apply metacognition. Do not miss opportunities for improvement.

The 'stages of change' model may be applied to feedback for improvement. The stages for the learner and instructor are:

  • Precontemplation: learner is not aware of, or denies, the need to change. Instructor helps the learner to understand, and provides additional information, clarifies expectations, and encourages self-assessment.

  • Contemplation: learner is aware of the need to change, but not yet committed to change. Instructor helps the learner to identify ambivalence, reinforce reasons for change, and identify barriers to change.

  • Preparation: learner is committed to change. Instructor reinforces change, supports strategies for change, and establishes measurable outcomes to monitor progress.


Finkelstein SR, Fishbach A. Tell Me What I Did Wrong: Experts Seek and Respond to Negative Feedback. Journal of Consumer Research. 2012;39(1):22-38.

Fisher CD. The Transmission of Positive and Negative Feedback to Subordinates. Purdue University.1984. (Accessed April 29, 2013).

Schartel SA. Challenges in anaesthesia education giving feedback - an integral part of education. Best Pract Res Clin Anaesthesiol. 2012;26(1):77-87.

Milan FB, Parish SJ, Reichgott MJ. A model for educational feedback based on clinical communication skills strategies: beyond the 'feedback sandwich'. Teach Learn Med. 2006;18(1):42-47.

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