Pendleton’s Rules: A Mini Review of a Feedback Method

Introduction

In a healthy feedback culture, both feedback providers (FBPs) and feedback recipients (FBRs) are comfortable with feedback [1,2]. Providing feedback is seen as an opportunity to make others better, receiving feedback is seen as a learning opportunity, and seeking feedback is seen as a strength [1]. In organizational cultures with unsafe learning or working environments, admitting what you don’t know is not done, mentioning that you are lacking skills, and pointing out areas which you would like to improve, is frequently perceived as a weakness. In healthcare, feedback cultures are often unhealthy. FBP’s are afraid to give honest feedback and therefore the feedback message is sugarcoated. FBR’s interpret receiving feedback as a sign of failure, and seeking feedback is interpreted as being insecure. Feedback training can help faculty, staff and learners to become more comfortable around feedback [3,4]. In this mini review we will focus on Pendleton’s Rules as a feedback method [5], and (1) explain Pendleton’s Rules, (2) review strengths and weaknesses and (3) discuss how this method can improve the feedback culture.

Pendleton’s Rules

David Pendleton, PhD -a psychologist from Oxford- came up with five ‘rules’ to guide feedback conversations, when training a group of Family Medicine Practitioners who had difficulty with giving feedback [5].

a) The FBP asks the FBR to mention two or three points that go well.

b) The FBP shares two or three points that go well.

c) The FBP asks the FBR to mention two or three points that can be improved.

d) The FBP shares two or three points for improvement and discusses strategies based on the input on closing the gap.

e) The FBP or FBR summarizes the most important points from the conversation.

When both the FBP and the FBR are familiar with Pendleton’s Rules it is an efficient use of time [6], it is possible to have a thorough, balanced feedback dialogue [7], about specific and actionable information that does not take more than five minutes.

When can Pendleton’s Rules be used?

Pendleton’s Rules are used in different settings such as (online) classrooms [8-10] and workplaces (e.g., clinical and laboratory setting, simulation, appraisal and assessment) [3,6,11,12]. Often, they are used to give feedback to our learners in a one-on-one situation. These learners are students, residents or fellows. However, Pendleton’s Rules are also used as a structure to give faculty feedback as part of their annual performance review [12].

In addition, they can be applied in a group situation [13]. Instead of a FBP leading the conversation a “neutral” third party, a mediator, leads the conversation, (a) asking the group what they thought did go well, followed by (b) asking the FBR what they thought did go well. The role of the mediator is to protect the feedback recipients against strong opinions in the group, and to ask clarification questions if the group feedback is not specific. Then the mediator asks (c) what can be improved according to the group and (d) asks the FBR what they think can be improved. The mediator finishes the conversation by (e) asking one of the parties to summarize the most important points.

Although Pendleton’s Rules are very frequently used in skills learning [11], the content of the feedback message can be applied to cognitive (what), affective (why), and meta-cognitive (how) content [14]. The Rules are widely applicable; in many different situations (one-on-one vs. group) for a diverse audience (learners and faculty) and on a variety of content (cognitive, affective and meta-cognitive).

Strengths and Weaknesses

Strength-Including the FBR

One specific feature of Pendleton’s Rules is that FBRs are invited to express their opinions. Why is it so important to include the FBR or learner? It is the teacher who is the expert, who has the overview, why should the learner be involved? When the learners or FBRs are asked what goes well or can be improved they are asked to self-reflect [15]. By answering these questions, the FBP will hear their opinion [15,16], and the FBP will have an idea why the FBR acted in the way they did. This is the reason why it is so encouraged to explore the learner’s or FBR’s motivation that drives their performance. Involving the FBR will make the feedback conversation automatic a dialogue, which is important for the feedback to be accepted.

Why is it important to ask the FBR first? In general -especially in a learning situation- a teacher has more power compared to the learner. The learner can become intimidated and will therefore paraphrase what the teacher is saying and share this as their own opinion. The fact that the learners have to give input first, gives the learner the opportunity to self-assess and reflect [15,16]. This information is crucial for the FBP. Based on what the FBR mentions the FBP will know now how to tailor the content and tone of the feedback message to the learners. For example, when the FBP gives feedback on a presentation and observed that the slides are too wordy and the colors are not contrasting, this message will be delivered differently compared to the situation in which the learner explains that the slides were the strength of the presentation. The learner’s self-assessment can guide the FBP in tailoring the message better to the learner’s needs and in this respect, it may help the message come across.

Strength - Balanced Feedback

“Why is it important to focus on what goes well? You don’t need to give feedback on things that go well, feedback is all about improvement!?” This question is frequently asked in training. Sometimes learners are not aware that they do things well. If it is not explained what goes well and why, FBPs take away a learning opportunity from the FBR who is not aware of it. By explaining clearly what you liked about FBR’s knowledge, skill, performance etc., and why you think this is a strength, you will reinforce the good behavior. From the literature we know that FBRs have different feedback propensities [17,18]. Some learners learn more from positive feedback -about what goes well- while other learners perceive they learn more from what can be improved - so called ‘negative’ feedback. When we focus on both aspects, we also help the learners that profit from positive feedback. It is a myth to assume that positive feedback is not contributing to our learning process [19].

Why is it important to address positive feedback first? Research on feedback order is inconclusive about what happens when the feedback order is reversed. However, it is known that humans often are focused on the negative, and all the attention goes out to what goes ‘wrong’, and the positive side of a performance -what goes well-, lacks attention. Further, the positive message helps the learner also to open up and receive feedback in a better way, and it can help to create a safe learning environment [20].

Downsides

Pendleton’s Rules have downsides as well [11, 21-27]. The literature mentions that FBPs find it sometimes hard to find positive points in FBR’s behavior [11, 24-27], or they have difficulty in separating the good points and the points for improvement [11]. Orsini describes that learner’s anticipation of points for improvement (‘critic’) is a limitation of the model [27].

When FBPs begin learning Pendleton’s Rules they feel uncomfortable using them, for example because the structure is perceived as too rigid [24]. In training they frequently mention that they find the language artificial. To make sure that the feedback method comes across as authentic it is important that the feedback provider finds their own language that fits them. That might take five or six tries. Some FBPs like to talk about “What goes well- What can be improved?” Others use: “What are some tops and tips”, or “What would you continue doing and what would you change?”.

When FBPs are not good at observing FBRs and they ask the FBR what did go well, they sometimes “parrot” the FBR (e.g.: “I think you are correct”, “I noticed this too”) without sharing their own thoughts. If this happens frequently, Pendleton’s Rules lose their impact. The learner feels they don’t learn from it. If they also do this related to the points for improvement, the FBRs might perceive Pendleton’s Rules as a method in which they dig their own grave.

Conclusion: Creating a Feedback Culture

Pendleton’s Rules are not the best, the only, or the most effective feedback method. Its benefits and strengths are often overlooked.

This method can easily be trained in faculty development, and it teaches uncomfortable faculty how to give feedback in a short amount of time by a set of five rules. This method clearly encourages a dialogue between the FBP and FBR in order to have a feedback conversation. It also stimulates the learner to reflect and self-assess. It addresses both good points and improvements and can be provided in a short amount of time. To make sure that the rules are effective, FBPs have to work on finding their own voice in the feedback conversation and also observe the learners closely so that the observation outcomes are at the core of the Feedback. Lastly, Pendleton’s Rules will give a simple ‘language’ to both the FBP and the FBR to help improving each other. These benefits can help the FBP and FBR to change the feedback culture and create a better learning and working environment.

Conflict of Interest

Both authors declare no financial interests or conflict of interest.

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