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Client Feedback to Nursing Students as a Teaching Tool in Mental Health Placements Miehling, Alicia 2016-10

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          CLIENT FEEDBACK TO NURSING STUDENTS AS A TEACHING TOOL IN MENTAL HEALTH PLACEMENTS   By   ALICIA MIEHLING   Bachelor of Science in Nursing, Thompson Rivers University, 2007     A SCHOLARLY PRACTICE ADVANCEMENT RESEARCH PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE  REQUIREMENTS FOR THE DEGREE OF     MASTER OF SCIENCE IN NURSING    In   THE FACULTY OF GRADUATE STUDIES AND POSTDOCTORAL STUDIES   (School of Nursing)   THE UNIVERSITY OF BRITISH COLUMBIA   Vancouver   October/2016     Alicia Miehling, 2016 CLIENT FEEDBACK AS A TEACHING TOOL  2 Table of Contents  ACKNOWLEDGEMENTS ....................................................................................................................... 4 CHAPTER 1: PLANNING A LITERATURE REVIEW OF CLIENT FEEDBACK TO NURSING STUDENTS AS A TEACHING TOOL IN MENTAL HEALTH PLACEMENTS .............................. 5 INTRODUCTION ............................................................................................................................ 5 SIGNFICANCE ............................................................................................................................... 6 PURPOSE AND RESEARCH QUESTION ........................................................................................... 7 METHODOLOGY ........................................................................................................................... 8 FEEDBACK – A THEORETICAL CONCEPT .................................................................................... 14 SUMMARY .................................................................................................................................. 16 CHAPTER 2: ANALYSIS AND FINDINGS FROM THE LITERATURE REVIEW ...................... 17 CLIENT FEEDBACK FOR MENTAL HEALTH NURSING STUDENTS ................................................ 17 NATURE OF CLIENT PARTICIPATION .......................................................................................... 17 SET UP OF FEEDBACK ................................................................................................................ 21 STAKEHOLDERS IN LEARNING .................................................................................................... 23 IMPACT OF FEEDBACK ............................................................................................................... 25 SUMMARY .................................................................................................................................. 27 CHAPTER 3: DISCUSSION OF THE FINDINGS ............................................................................... 29 CHAPTER 4: CONCLUSION AND RECOMMENDATIONS ........................................................... 35 REFERENCES  ......................................................................................................................................... 40 CLIENT FEEDBACK AS A TEACHING TOOL          3 Abstract  This paper utilized an integrative literature review methodology to explore the use of client feedback to nursing students as a teaching tool within mental health clinical placements. The primary question guiding this review was: How has client-provided feedback been integrated and utilized for nursing students in mental health clinical education? Despite the limited research completed in this area, this review illuminates what is currently understood. Ten articles were selected and reviewed, as guided by the main research question and four sub-questions. The findings of the review revealed that client provided feedback supports the concept of client-centered care, and also works to counteract the power imbalances that are present within the health care system. Client participation can take many forms, ranging from feedback in a simulation setting, to not only giving feedback, but being a key part of developing feedback tools and evaluating the process overall. The set up of the feedback relationships is an important consideration, particularly the provision of support and education for all participants to prepare them for their role in giving or receiving it. The primary stakeholders for this research were clients, students and clinical instructors. The potential impact of client feedback is broad; however, the core purpose for seeking it is to increase the empathy for, and understanding of, the clients we work with, while also providing learning opportunities for students, which will enhance the connections and care provided. Several important recommendations were identified within this review, which are of value to consider in future exploration of this topic. Keywords: mental health, clinical nursing education, client feedback, nursing education, client participation, student learning  CLIENT FEEDBACK AS A TEACHING TOOL  4 Acknowledgements  I am extremely grateful for my advisor and supervisor Dr. Geertje Boschma, PhD. Her continuous support and guidance for not only this project, but throughout the master’s program has been key my success. Thank you for being my mentor.  I am also very appreciative of Dr. Jennifer Baumbusch, PhD, who was my second committee member for this SPAR project. Your perspectives and recommendations helped significantly shape and refine this work. Thank you for all of your contributions.  It is also very important to me that I thank the people with whom I work. To my colleagues, thank you for inspiring me day in and day out with the work you do. To the students, thank you for your keen interest and desire to learn about the mental health field, the future is bright. To the clients and their families, thank you for your insights, you are at the heart of what we do, and the reason for my passion.  Last but not least I must thank my family. To my dear parents and brother, thank you for your love and support, always. To my husband Adam, there are truly no words, you are my rock and my biggest fan. I love you. To my son Cole, my greatest gift. Thank you for giving me my motivation to keep pushing.   CLIENT FEEDBACK AS A TEACHING TOOL  5 CHAPTER 1: PLANNING A LITERATURE REVIEW OF CLIENT FEEDBACK TO NURSING STUDENTS AS A TEACHING TOOL IN MENTAL HEALTH PLACEMENTS  Introduction Current health care policy directs health professionals to acknowledge the importance of involving clients in health service design, delivery, research, and evaluation (Stickley, Stacey, Pollock, Smith, Betinis, & Fairbank, 2009). Clients possess untapped expertise that can be beneficial to many aspects of health care (Stickley et al., 2009). Within the mental health field, starting in the 1970s, clients had an active role in the shift towards more community-based mental health care (Boschma, Davies, & Morrow, 2014). Deinstitutionalization and the recognized importance of client-centred care became more prominent and prompted increased attention towards the clients themselves. Words such as engagement, collaboration and empowerment began to infiltrate mental health policy (Speers & Lathlean, 2015). More recently, the recovery model has been emphasized as a pillar of modern mental health programming (Department of Health, 2011). This model highlights client expertise regarding mental health and focuses on strengths based approaches, all while advocating for partnerships between health care professionals and clients. Client insights and expertise have the potential to deepen registered nursing students’ understanding of mental health challenges during their clinical training, while also increasing their appreciation of the strength and coping mechanisms that clients possess. An understanding of the person behind the illness is imperative to enhancing connections and quality of care. Client provision of feedback to nursing students is one way to tap into the client’s knowledge and life story, and is a concept that will be discussed in greater depth moving forward.   CLIENT FEEDBACK AS A TEACHING TOOL  6 Significance Increased client engagement in policy and service development is a best practice standard throughout the healthcare system; however, for the purposes of this paper, this phenomenon will be explored within the specific context of the mental health system. It is important to note when considering the mental health system that the shift in focus from institutionalized care to a client-centered focus has impacted not only the clinical environments, but also the ways in which post-secondary education of health care professionals and research processes are approached. Within nursing education for example, the concept of evidence-based practice is now more inclusive of the client role, for their expertise and experience is emphasized (Debyser, Grypdonck, Defloor, & Verhaeghe, 2010). Mental health clients are more regularly invited into the classroom setting to speak with student groups, just as students are encouraged to focus largely on client needs and individualized plans of care within the clinical setting (Bennett & Baikie, 2013). Additionally, some nursing regulatory bodies within England and Scotland have started to require that nursing programs make it clear how clients are contributing to the assessment of nursing students across the various specialty health care areas (Masters & Forrest, 2010; Mc-Mahon-Parkes, Chapman, & James, 2016). It is anticipated that this is a trend that will continue moving forward. However, what is less clear is how this contribution to assessment is to be best achieved. Furthermore, the inclusion of clients in assessment of students has only been explored in a handful of studies; therefore, best practice approaches and standardized tools to collect this feedback do not exist at this time and need to be developed. Repper and Breeze (2007) commented that the lack of regular involvement of mental health clients in the formal assessment of nursing students, despite the societal shift towards this approach, is inconsistent with the ‘client as expert’ concept. Debyser et al. (2010) agreed, stating that not only are clients experts of their own conditions, but CLIENT FEEDBACK AS A TEACHING TOOL  7 they also experience nursing care first hand, so are well positioned to comment on nursing student practice.  In addition to aligning with the current trends and best practice approaches of involving clients within mental health services (Morgan & Sanggaran, 1997), and healthcare in general, including client feedback and engagement in education and in the provision of feedback from clients to nursing students has been identified as a powerful teaching tool, which has positive impacts on student learning (Webster, Goodhand, Haith, & Unwin, 2012). According to Grav, Lynsfjord, and Helizen (2010), mental health nursing should emphasize the partnership between nurses and clients, because “if the mentorship offered to students during their mental health clinical placement is based on such a partnership it may help the students to develop their professional roles” (p. 4).  Given the current state of knowledge in this area, this paper will focus specifically on a review of existing studies of client feedback as a teaching tool in the context of mental health placements for nursing students. A description of how this review will be undertaken is outlined in greater detail in the purpose and research question section below. Many of the studies included within the review are exploratory in nature as this is a topic that has not been researched extensively. Following this section, I will outline the methodology used for this review, that is, an integrative literature review. The chapter will end with an overview of giving feedback as a theoretical framework that has guided this review. In Chapter 2 I will report on the findings from the integrated literature review. Purpose and Research Question The purpose of this integrative literature review is to examine how client feedback to nursing students can be utilized as a teaching tool within mental health clinical learning CLIENT FEEDBACK AS A TEACHING TOOL  8 placements. The concept has gained momentum more recently, and promotes the progression towards a system that truly supports a collaborative partnership between clients and health care professionals (Stickley et al., 2009). The research question guiding the analysis is: How has client-provided feedback been integrated and utilized for nursing students in mental health clinical education?  There are four sub-questions that will further shape the literature review:   What is the nature of the client feedback in nursing student learning?   How is it set up in terms of learning?  Who is involved in the learning process? (The primary focus is on student learning and the student learning process)  What is the impact of the feedback experience for client, students and clinical instructors?  Methodology The integrative literature review methodology was used for this paper. Broome (1993) describes the integrative review as a review method that summarizes empirical or theoretical literature in an effort to better understand health care issues or phenomena. Rather than being focused primarily on evidence drawn from randomized control trials, the integrative review allows for a variety of methodologies to be explored, which allows for the inclusion of multiple perspectives on a topic (Whittemore & Knafl, 2005). Examples of the types of research that may be included in integrative reviews include: experimental and non-experimental research, as well as theoretical and empirical literature. The use of data analysis strategies when carrying out an integrative review have been highlighted as a priority of the process. The first stage of any integrative review involves clear problem identification and an explanation of the purpose of the CLIENT FEEDBACK AS A TEACHING TOOL  9 review, with the second stage involving a well-defined search strategy (Whittemore & Knafl, 2005). The third stage involves data evaluation, which includes a consideration of the authenticity, methodological quality, and value of the primary sources included (Kirkevold, 1997). The fourth and final stage pertains to data analysis; the two goals of this stage are to: interpret primary sources in a thorough and unbiased way, and then to synthesize the evidence together (Whittemore & Knafl, 2005). The stages just outlined help improve accuracy and reduce some of the challenges associated with the integrative review methodology, such as a heightened risk of error and bias (Whittemore & Knafl, 2005). The use of this approach, and following these steps and stages, guided the way in which I carried out my analysis and the evolution of this paper. It is not difficult to find research about the importance of involving clients in health care education; however, it is challenging to find information about the client’s specific role in clinical education within the nursing field. For the purposes of this review the focus was specifically on adult client involvement in providing feedback to nursing students during their clinical rotation. Although my particular interest is in undergraduate nursing students in their mental health clinical rotation, articles involving nursing student (undergraduate or graduate) rotations in other clinical setting were also considered to provide a more comprehensive look at how this topic is currently understood.  The involvement of clients in the assessment of student practice is discussed and supported within the literature for all health care professions (Masters & Forrest, 2010; Repper & Breeze, 2007; Speers, 2008). Although the literature review (the findings of which are reported in Chapter 2) is not inclusive of research from other disciplines, Chapter 3 and 4 will compare the findings from the review of nursing literature on this topic with some of the learnings from CLIENT FEEDBACK AS A TEACHING TOOL  10 the social work field in particular as a way to supplement the findings from the literature review of nursing scholarship and support recommendations moving forward. The social work field has been identified as leading practice in regards to client involvement (Masters & Forrest, 2010). Both nursing and social work education is designed to assist students in developing and enhancing their professional practice, therefore, literature on client feedback as an educational tool from the social work field is also deemed relevant to this examination, and may be helpful in advancing nursing practice in this area (Masters & Forrest, 2010). Search Strategies The CINAHL, MEDLINE, PsycINFO, and PubMed databases were searched for the 2005-2015 period. The search strategy included the following combination of key words: mental health clients or patients, nursing student, and feedback. Search terms were used in combination with one another. The search of the four databases resulted in the identification of 28 articles. When I initially undertook this search I located 146 articles, but after after adapting my search terms to the specific ones listed, I was able to make the search clearer. My interest in the topic of client participation in student evaluation stems from some interesting articles I came across on this topic in a previous course, so I was also able to utilize a few of these identified research studies, as well the findings from a paper I completed in that class (Miehling, 2016). The terms services users, patients and clients were used interchangeably throughout the literature, but for the purposes of this paper the term client will be utilized.  The inclusion criteria for the selection of relevant papers for the review included: nursing students in undergraduate or graduate education, and studies involving the provision of feedback provided by clients in the clinical setting. The exclusion criteria included: education solely in a classroom setting, no discussion on the concept of client-provided feedback, and no involvement CLIENT FEEDBACK AS A TEACHING TOOL  11 of nursing students. Two articles, although closely linked to the topic of clients’ roles in education, were removed, but are still worth noting. Manninen, Henriksson, Scheja and Silen’s (2014) article was removed as it did not specifically refer to the feedback process, although it did speak about components of the client-student relationship. The research by Bennett and Baikie (2013) also had some very valuable insight to lend on the topic of client as educator, but the focus of the article was on client involvement in the classroom setting as a teacher, not the clinical environment providing feedback.  In all but two studies (Masters & Forrest, 2010; Schwindt & McNelis, 2015), the perspectives of the clients were considered. These latter two studies are included in the integrative literature review because although they are missing the clients’ perspectives, they provide insight on the direct impact of client provided feedback on student learning, which contributes to a deeper understanding of the student’s role in the feedback relationship. The initial intention was to exclude literature older than 10 years, but two studies (Twinn, 1995; Morgan & Sanggaran, 1997) were included despite their earlier publication dates. Twinn’s (1995) research is viewed as a landmark study for the topic of client participation in student learning, and was frequently referenced by other articles. Similarly, Morgan and Sanggaran’s (1997) study was often mentioned within other research, and provides some valuable insights into client feedback for students. The focus of this paper is on the mental health field; however, articles were not excluded solely because they did not focus on the mental health field. If the research had something to offer in terms of learning about the feedback process involving clients and nursing students, they had the potential to inform the mental health field moving forward. In addition to the two articles above, eight more articles were selected (Debyser et al., 2010; Masters and Forrest, 2010; McMahon-Parkes et al., 2016; Schwindt & McNelis, 2015; CLIENT FEEDBACK AS A TEACHING TOOL  12 Speers, 2008; Speers & Lathlean, 2015; Stickley et al., 2010; Webster et al., 2011). This search resulted in ten relevant studies being selected and included in the integrative literature review. They are presented chronologically within Table 1.  Table 1: Chronological overview of articles included within the Integrative Literature Review Study Title Authors Year Study Design/Sample Size Common themes Creating reality or contributing to confusion? An exploratory study of client participation in student learning Sheila F. Twinn 1995 Exploratory, multi-stage mixed research – qualitative and quantitative methods 24 client participants 28 student participants 28 instructor participants Teaching tool Optional client participation Support from practitioners Debriefing process Client-centred approach to student nurse education in a mental health practicum: An inquiry Stephen Morgan, & Raj Sanggaran 1996 Mixed methodological design – qualitative and quantitative  74 client participants 43 student participants Teaching tool Client role in student learning Individual feedback Client-centered Nurse education  Service user involvement in the assessment of a practice competency in mental health nursing – Stakeholders’ views and recommendations Janey Speers 2008 Qualitative  24 participants (5 service users, 7 students, 4 ex-students, 6 mentors, and 2 lecturers) Optional client participation Individual feedback Implementation plan Anonymity  Involvement of inpatient mental health clients in the practical training and assessment of mental health nursing students: Can it benefit clients and students?  Bart Debyser, Mieke H.F. Grypdonck, Tom Defloor, & Sofie T.L. Verhaeghe 2010 Qualitative  15 participants (7 clients, 4 students, 2 nurses, and two teachers) Teaching tool Empathy Enhance communication Recovery  CLIENT FEEDBACK AS A TEACHING TOOL  13 How did I do? An analysis of service user feedback on mental health student nurses’ practice in acute inpatient mental health placements.  Hugh Masters, & Susanne Forrest 2010 Qualitative  69 student participants Teaching tool Implementation plan Debriefing process Empathy Recovery  The practice assessment of student nurses by people who use mental health services Theodore Stickley, Gemma Stacey, Kristian Pollock, Angie Smith, Janet Betinis, & Sarah Fairbank 2010 Qualitative  Stage 1:  5 participants  Stage 2:  15 student participants 16 service user participants Teaching tool Implementation plan Debriefing process Empathy Vulnerability  The development of service users in the provision of verbal feedback to student nurses in a clinical simulation environment Brian J. Webster, Kate Goodhand, Mark Haith, & Rachel Unwin 2012 Qualitative  18 patient volunteer participants Empathy Vulnerability Individual feedback Simulation Integrating simulation into a reflection-centered graduate Psychiatric/Mental health nursing curriculum. Rhonda Scwindt, & Angela McNelis 2015 Qualitative  15 student participants Simulation Self-awareness  Service user involvement in giving mental health students feedback on placement: A participatory action research study. Janey Speers, & Judith Lathlean 2015 Qualitative  Group 1:  6 stakeholder participants (1 mentor, 4 service users, and lead researcher)  Group 2:  25 participants (9 students, 6 mentors, 10 service users)  Vulnerability Self-awareness CLIENT FEEDBACK AS A TEACHING TOOL  14 The views of patients, mentors and adult field nursing students on patients' participation in student nurse assessment in practice Kate McMahon-Parkes, Linda Chapman, & Jayne James  2016 Qualitative  13 participants (4 patients, four nurses, and 5 nursing students) Teaching tool Recovery (empowerment) Anonymity Vulnerability Self-awareness  Feedback – A Theoretical Concept The feedback process in clinical nursing education is a dynamic and fluid one. It evolves and changes depending on the participants, and is a central component of the learning that takes place within the clinical environment. In order for clinical evaluation to be most effective, feedback about performance and opportunities for improvement should be provided to students in a continuous manner (Gaberson, Oermann, & Shellenbarger, 2015). Before moving any further with this discussion, we turn to the research by Hattie and Timperley (2007) for their definition of the term:  Feedback is conceptualized as information provided by an agent (e.g., teacher, peer, book, parent, self, experience) regarding aspects of one's performance or understanding. … Feedback thus is a "consequence" of performance. (p. 81)  Feedback and instruction are intertwined in such a way that it is not solely a correctional review, but rather an opportunity to fill the gap between what is understood and what is aimed to be understood (Hattie and Timperley, 2007). Feedback is often described as being either directive or facilitative (Archer, 2010). Directive feedback informs learners of what requires correction, whereas facilitative feedback involves the provision of comments to assist learners in making their own revisions (Archer, 2010). Considering these points within the context of the student-client relationship, the end goal is not for the client to correct or direct student behaviour or CLIENT FEEDBACK AS A TEACHING TOOL  15 clinical skills, but rather to facilitate and guide students toward a clearer, shared understanding and way of being. Any, and all, feedback should not end with the delivery of the feedback message, but should also be accompanied by further instructions to help the student identify learning activities and opportunities for growth. This will help the student begin to “judge their own performance, identify resources for their learning, and use those resources to further develop competencies” (Gaberson et al., 2015, p. 326).  With the shift towards a more consumer focused system, consideration of how to employ client feedback in relation to the assessment of nursing students in a clinical setting is becoming much more crucial (McMahon-Parkes et al., 2016). In addition to considering who is involved in the feedback relationship, it is important to acknowledge the setting in which the feedback occurs. More recently there has been research completed on the value of simulated feedback exchanges, as opposed to the ‘real world’ feedback that occurs within the clinical environment (Schwindt & McNelis, 2015; Webster et al., 2012). In the next chapter I will discuss the similarities and differences between these two settings in greater depth, but a key point to acknowledge at this time is that feedback, regardless of the setting, “has been identified as a positive and powerful contributor to aid in learning” (Webster et al., 2012, p. 134).  Gaberson et al. (2015) outlined several principles for providing feedback to students as part of the clinical evaluation process. These principles were developed with the clinical instructor in mind, however several are valuable to consider within the context of client provided feedback as well. Firstly, specific feedback is deemed more valuable to learners than a general description (Gaberson et al., 2015); therefore, clients should be encouraged to share a specific example or detail about student practice, rather than make general comments. Secondly, feedback should be given to students at the time of learning or immediately following it CLIENT FEEDBACK AS A TEACHING TOOL  16 (Gaberson et al., 2015). Research shows that the longer the period of time between the activity and the feedback, the less effective the feedback is (Gaberson et al., 2015). Thirdly, the amount of feedback needed changes (Gaberson et al., 2015). In the beginning of a new clinical rotation, students may require more frequent feedback; however, as they become more competent they can begin to assess their own performance and learning needs. There are several factors that affect student achievement most significantly, with feedback being identified as one of the most beneficial contributors (Hattie & Timperley, 2007). Still, the implementation of the feedback process should not be viewed as an interaction separate from all of the others, but rather for it to truly be integrated within the day to day clinical interactions, and therefore it is required that “feedback is embedded implicitly and explicitly in all activities” (Archer, 2010, p. 106). Summary  This paper will add to current understandings of client feedback as a teaching tool in nursing education in the mental health clinical setting, and the impact it has on the clients, students and clinical instructors involved. In this chapter I have outlined the plan, objectives, research questions, methodology and key concept of feedback guiding this integrative literature review.  The subsequent chapters will explore the ten research articles included in this literature review in order to expose what is currently known about the topic (Chapter 2), while also discussing the implications of the findings and potential next steps (Chapters 3 and 4).CLIENT FEEDBACK AS A TEACHING TOOL  17 CHAPTER 2: ANALYSIS AND FINDINGS FROM THE LITERATURE REVIEW The following chapter explores the ten studies selected for this review by first analyzing the main research question: How has client-provided feedback been integrated and utilized for nursing students in mental health clinical education? The chapter then looks more specifically at the research sub-questions, which seek to explore the nature of the client participation, how the feedback is set up in terms of learning, who is involved in the learning, and finally the impact of the feedback experiences on clients, students and clinical instructors. Client Feedback for Mental Health Nursing Students  There is a limited body of evidence regarding client assessment of nursing students, both within, and outside of, the mental health nursing field (Stickley et al., 2010). The ten research articles included within this review were selected because their research focussed on client involvement in providing feedback to nursing students within a clinical setting. This provision of feedback aligns with the values of client-centered care, and more specifically seeks to equalize any perceived power imbalances. It also enhances the quality of the interpersonal interactions between the client and student, which ultimately improves the client’s perception of the health care system, and “adds legitimacy to the case for asking the people in a relationship for feedback about the relationship” (Speers & Lathlean, 2015, p. 85). The following sections of this chapter will analyze the sub-questions that guided this review.  Nature of Client Participation in the Provision of Feedback to Students This section will highlight how clients were involved in providing feedback to students. Within the selected studies, client participation varied from practicing giving feedback in a simulation setting (Webster et al., 2012), to being involved in not only giving feedback in a CLIENT FEEDBACK AS A TEACHING TOOL  18 clinical environment, but also in helping develop feedback tools, as well as in evaluating the feedback process. Regardless of the nature of their participation, clients appeared eager to be involved, and valued opportunities to express their views and be taken seriously (Debyser et al., 2010; Masters & Forrest, 2010; Stickley et al., 2010). It was evident that clients wished for more reciprocal relationships with health care professionals, with a desire to give back to services, as well as take from them (Speers & Lathlean, 2015). They acknowledged they had something to offer students, and also shared how their role in student learning could help overcome the theory practice gap (Twinn, 1995). One client emphasized that “they’ve got to get experience or they don’t get good at the job… there are things that happen in real families that wouldn’t crop up in books” (Twinn, 1995, p. 293). Using a simulation environment to help clients learn about providing feedback is a concept that has not been explored in great depth. Two of the ten articles included in this literature review focused on the use of a simulation setting (Schwindt & McNelis, 2015; Webster et al., 2012). The general intent of this approach is to allow both client volunteers and nursing students to role play complex scenarios involving social interactions and communication skills in a simulated setting (Webster et al., 2012). This experience impacts skill development, confidence, and insight into progress for both clients and students (Webster et al., 2012). Webster et al.’s (2012) described that their client volunteers were currently, or had previously been, clients, so they had experience receiving mental health care. Similar to Webster’s (2012) research, Schwindt and McNelis (2015) also studied client provision of feedback to nursing students in a simulated mental health setting, but were much more focused on student learning specifically. Two key recommendations came out of their research; firstly, receiving feedback CLIENT FEEDBACK AS A TEACHING TOOL  19 directly from the client was preferred, and secondly, receiving feedback in the moment was the most impactful (Schwindt & McNelis, 2015). These findings are consistent with Gaberson et al.’s (2015) principles for providing feedback to students that were outlined in Chapter 1, which emphasize the importance of direct and timely feedback interactions.  Despite several studies emphasizing a preference for in the moment feedback, in practice, client feedback was often summative in nature, occurring at or near the end of the nursing student’s clinical rotation. Verbal or written communication was the primary method of providing feedback, with questionnaires frequently being used to prompt client conversations with students (Speers & Lathlean, 2015). The focus of the feedback was not consistent; with some studies asking clients about student nurse performance (Morgan & Sanggaran, 1997), and others specifically asking clients what qualities they’d like to see in mental health nurses (Stickley et al., 2010). A few others explored clients’ experiences providing feedback and their opinions about their role in student learning (Morgan & Sanggaran, 1997; Twinn, 1995). Speers (2007) asked clients about the advantages and disadvantages of being involved in practice competency assessments in general. From these latter three studies it became clear that clients saw their role in student learning as both personally empowering and in congruence with the concept of client-centered care (Morgan & Sanggaran, 1997; Speers, 2007). Another perceived advantage was their ability to provide students with the reality of practice, which was an opportunity to teach things that wouldn’t show up in books (Twinn, 1995). A potential disadvantage perceived by clients were the repercussions and impact of giving negative feedback to students (Speers, 2007). This raises some red flags about client involvement with students who are struggling because “although findings suggest clients have a major role to play within this CLIENT FEEDBACK AS A TEACHING TOOL  20 component of student learning, the extent to which this process could be implemented with students whose performance is failing or borderline is questionable” (Twinn, 1995, p. 295). Several studies explored client involvement in the development and implementation of feedback tools. McMahon-Parkes et al. (2016) studied clients as one group of stakeholders in the creation of a feedback tool. Similarly, Morgan and Sanggaran (1997) and Speers and Lathlean (2015) worked collaboratively with clients to construct a tool they could use when providing feedback to students. In all three studies the clients were one of the key working group members, which also consisted of clinical instructors, nursing students, and nurse mentors (McMahon-Parkes et al., 2016; Morgan & Sanggaran, 1997; Speers & Lathlean, 2015). None of the studies were particularly explicit about how the clients were involved aside from the initial consultation as a part of the working group. Speers and Lathlean (2015) did note that the questionnaire devised by key stakeholders, including clients, underwent revisions in response to feedback from students and clients who, in addition to creating it, also tested it out.  Stickley et al. (2010) believed that clients should be involved and engaged throughout their entire research project. As such, the assessment tool they developed was designed in collaboration with clients. Clients also participated in focus groups and interviews to evaluate the tools prior to them being piloted. For example, part way through the creation of their feedback tool, Stickley et al. (2010) completed interviews with staff, students and clients to identify potential issues and initial feedback on the tool while it continued to be developed. These preliminary findings uncovered that the staff, students and clients shared some common views about the project, which ranged from positive and negative implications. Each of the groups members agreed that the group could certainly positively enhance client-centered care and add to our understanding on new ways to complete student assessments (Stickley et al., 2010). On the CLIENT FEEDBACK AS A TEACHING TOOL  21 other hand, staff and students expressed concern about the negative impact that critical feedback could have, as well as the potential pressure that clients may feel to participate (Stickley et al, 2010). These concerns were not shared by the clients; however, clients did express reluctance to give any critical feedback to students due to their discomfort in providing it (Stickley et al., 2010). The next stage of client involvement followed the formal implementation of the tool. Fifteen student nurses and sixteen clients participated in this assessment process, and all of them were interviewed following their participation. Researchers hoped to understand how the feedback process influenced both practice and working relationships (Stickley et al., 2010). Clients were also encouraged to make suggestions for the future implementation of the project (Stickley et al., 2010).  From the studies which discussed evaluation and assessment tool development it became clear that clients were a key member of this work. For one, client involvement in research “is justified by virtue of their direct experiences of the issues under study” (Stickley et al., 2010, p. 21). None of the selected studies articulated what clients contributed specifically to tool development, nor did they indicate their conclusions about the tools. It was noted however that client feedback informed next steps in the project work (Morgan & Sanggaran, 1997; Speers & Lathlean, 2015; Stickley et al., 2010). This concludes the conversation about the nature of client participation. In the following section the set up of the feedback relationship between clients and students will be explored. Set Up of Feedback There were multiple variables that effected how feedback was given by clients and received by students. The following section will focus on how the set up of the feedback relationship influenced the learning that occurred. Some of the set up, for both clients and CLIENT FEEDBACK AS A TEACHING TOOL  22 students, was approached similarly, and some preparation differed. I will discuss the similarities first, and then focus on any differences. Several studies noted the importance of emphasizing the optional nature of participating in the research studies. Speers (2007) required all participants to opt into the study after receiving information about the project. Similarly, Debyser et al. (2011) prepared participants by outlining the study’s purpose, while also emphasizing that participation was voluntary. To further reduce any perceived pressure to participate, Morgan and Sanggaran (1997) emphasized that participants’ involvement would in no way impact care given or student assessment. Providing support and education to participants to prepare them for their role in giving feedback is critical to the success of the interaction. Strategies used to accomplish this include: question and answer sessions at the beginning of a clinical rotation, and the use of written documents such as letters, pamphlets, and guidelines (Debyser et al., 2010; McMahon-Parkes et al., 2016; Morgan and Sanggaran, 1997; Spears & Lathlean, 2015).  Two of the studies developed training programs and curriculum about feedback. One program focused on training students for their role, and the other was directed at clients. Masters and Forrest (2010) provided all student study participants with written guidelines about how to obtain feedback from clients, in addition to preparatory classroom sessions on the topic. These sessions discussed: how to gain feedback, challenges that may be encountered, and different ways to collect feedback (written, verbal etc.). A conversation about the two main ways to elicit feedback from clients was also addressed; first, using naturally occurring windows of opportunity, and second, asking direct questions about their practice (Masters & Forrest, 2010). Webster et al.’s (2012) educational training program was developed for client volunteers who were providing feedback; their sessions included education on the importance of verbal CLIENT FEEDBACK AS A TEACHING TOOL  23 feedback, models of feedback, barriers to the process, and examples of helpful/unhelpful interactions. Not all studies were explicit on how client preparation for feedback occurred (Speers, 2007; Stickley et al., 2010; Twinn, 1995); that being said, some of these studies focused more on the perceptions of feedback, than the actual gathering of it. As emphasized by this section, the set up of the feedback relationship to prepare clients to give it, as well as students to receive it, is a critical component to consider when exploring this topic. The following section will provide an overview of the key stakeholders in learning within this feedback relationship. Stakeholders in Learning  The primary stakeholders within the feedback relationship are clients, students and clinical instructors. There were other individuals involved in the clinical setting who influenced the interactions, such as nursing staff, other health care professionals and family members, but they will not be the main focus of this discussion. Each stakeholder group will be addressed separately below.  Clients  Mental health clients were central to the learning that occurred, as they not only provided the feedback, but received the care within the context of the health care system. Consideration of criteria for inclusion or exclusion of clients in the research was very important in each study. Factors such as physical or psychological vulnerability, and an inability to provide valid consent and permission were a couple of reasons for excluding clients from giving feedback to students (McMahon-Parkes et al., 2016; Speers, 2007). Being over 65 years old, was exclusion criteria utilized by one study, yet the rationale for this age restriction was not indicated (Spears & Lathlean, 2015). The definitions of what constitutes vulnerability or incapability were not CLIENT FEEDBACK AS A TEACHING TOOL  24 explicitly defined (McMahon-Parkes et al., 2016; Speers, 2007), however it is anticipated that there were parameters that guided the determination. Making decisions about capability/incapability can be challenging, and are certainly not straight-forward in nature.  Students  Students were another key group of the feedback relationship, and were most often engaged in the feedback exercise as a part of their undergraduate or graduate clinical experiences. Morgan and Sanggaran (1997) emphasized the voluntary nature of their participation, giving students an option to be involved in receiving feedback from clients. Speers and Lathlean (2015) also acknowledged the risk of participants, including students, to feel pressured to participate due to the power imbalances present within the teacher-student relationship. As such, they chose to anonymise participants.  There are several qualities that clients valued when interacting with the students for feedback discussions, including: friendliness, availability and positive attitudes. All of these traits made the students more approachable, and in the eyes of the clients, emphasized the students’ abilities to “relate to them as people rather than in terms of their mental health problems” (Masters & Forrest, 2010, p. 16).  Clinical Instructors   Clinical instructors, although not directly involved in the provision of feedback, were seen as critical to the learning that came from the feedback relationship. They played a pivotal role in acknowledging the importance of a client-centred approach, as well as helping students maintain a client focus throughout their clinical placement (Morgan & Sanggaran, 1997). Instructors also acted as advocates for involving clients in practice assessments if this was not already common practice with the clinical setting (Masters & Forrest, 2010). The presence of CLIENT FEEDBACK AS A TEACHING TOOL  25 instructors for advice and discussion was identified by clients as important, for as eager as clients seemed about their role in student learning, they also emphasized that back-up support might be required (Twinn, 1995).   This concludes the conversation about the three main stakeholders in the feedback relationship. The final section of this chapter will now analyze the impact of feedback for the client, student and clinical instructor groups, before moving onto a discussion of the findings in Chapter 3. Impact of Feedback  The following section will discuss the impact of providing feedback or being engaged in the feedback process on clients, students, and clinical instructors. Clients Clients consistently expressed a desire to be viewed as equals with health care professionals, while also advocating for positive changes in the mental health system (Speers & Lathlean, 2015). Providing feedback to students enhanced this reciprocal relationship, and acknowledged the expertise that clients possess. Speers and Lathlean’s (2015) found that clients were noted to be the most enthusiastic group of participants in their study, which also included students and instructors. Clients recognized the impact that their feedback had on student practice, but often perceived it to have less importance in comparison to that provided by an instructor or nurse (Debyser et al., 2011). They expressed empathy and concern for students, along with a strong desire for their feedback to do no harm (Webster et al., 2012). Clients also shared that the final responsibility for pass/fail decisions should remain with the clinical instructor, but that their feedback could certainly assist in determining student competence and learning (Speers, 2007).  CLIENT FEEDBACK AS A TEACHING TOOL  26  Debyser et al. (2010) studied, in detail, the factors that influenced the impact of client feedback. They found that feedback had more value and meaning when provided within a safe environment, which include the following variables: knowing each other, having clear expectations, and following a clear framework (Debyser et al., 2011). The presence of facilitating versus complicating factors in the student and client were also deemed impactful. Facilitating factors include person centeredness, validating attitudes, and appropriate timing in student learning process (Debyser et al., 2011). Complicating factors include task centeredness and avoidance of contact (Debyser et al., 2011). Students  The opportunity to receive feedback from clients was invaluable for students. Not only did it have the potential to provide encouragement, it could also increase self awareness and contextual empathy (Debyser et al., 2011; Masters & Forrest, 2010). Contextual empathy “relates to the purpose that the feedback serves in helping students to appreciate service users’ experiences of acute care” (Masters & Forrest, 2010, p. 17). For example, recording how client boredom or lack of staff availability negatively impacted clients, provided opportunities for students to be more aware of what good nursing care looks like, and also encouraged refection on the type of nurses they would like to be (Masters & Forreset, 2010).  Client feedback also helps promote continuity in the learning process (Debyser et al., 2011). Frequently within the clinical setting there is inconsistent or limited mentorship due to the busy nature of the setting. Clients are often present more consistently during clinical placements, and as a result can play a key role in student learning (Debyser et al., 2011).   CLIENT FEEDBACK AS A TEACHING TOOL  27 Clinical Instructors Clinical instructors played an essential role in facilitating the feedback process (Twinn, 1995). Not only for the selection of appropriate clinical settings, but also to support clients and students, monitor learning, and assist in reflecting on the experience (Twinn, 1995). There was limited discussion within the selected articles about how client feedback to students impacted the clinical instructors. Summary  The engagement of clients in the provision of feedback has the potential to significantly revamp the mental health care system as we know it. From the selected studies it became clear that it is important to strive towards a system that embraces client provided feedback, for not only does this approach embody the concept of client-centered care, but also works to counteract the power imbalances that are present within the health care system. Client participation can take many forms ranging from providing feedback in a simulation setting, to not only giving feedback, but being a critical part of developing feedback tools and evaluating the process overall. Providing support for the key members of the feedback relationship is imperative and can range from pamphlets and guidelines to formalized education sessions. Many individuals influence the interactions that occur within a clinical environment, but the for purposes of these discussions, the key stakeholder were clients, students and clinical instructors. The impact of client feedback is vast; however, the core purpose for seeking it is to enhance the empathy and connections within our health care system regardless of the roles each of us have.  Specifically for mental health clients, their involvement not only empowered their voice to be heard, but also allowed them to practice the skills critical for their recovery and connection to society (Debyser et al., 2011). It is through listening to client experiences, and accounts of CLIENT FEEDBACK AS A TEACHING TOOL  28 what works, that we can begin to more deeply understand the important role they play, and how our health care system can be adapted to better meet their needs. An important gap identified throughout the literature was the inconsistent way in which client feedback was sought and utilized. This unfortunately perpetuates the uncertainty about the role the client should play in the feedback relationship. The next chapter will discuss the findings of the literature in greater detail by analyzing concepts connected to feedback including resiliency and vulnerability, challenges of implementation, and changes necessary to consistently utilize such an approach.    CLIENT FEEDBACK AS A TEACHING TOOL  29  CHAPTER 3: DISCUSSION OF THE FINDINGS  The previous chapter presented the analysis and findings of the literature surrounding client provided feedback to nursing students during their clinical rotation. This chapter will further discuss the findings from the integrated literature review by first highlighting the relationship between resiliency, vulnerability and feedback. There will then be a conversation about the perceived challenges of client provided feedback; with the chapter closing with a discussion regarding the changes needed within health care to support increased client engagement. Resiliency, Vulnerability and Feedback  Resiliency is often described as existing along a continuum with vulnerability, with resiliency being viewed as an opportunity for positive growth and adaptation following adversity, and vulnerability being defined as a struggle to achieve such growth (Goldberg, 1972; Richardson, 2002). There are multiple internal and external factors that promote resiliency and minimize vulnerability. Although several of these factors are traits that individuals inherently possess, there are opportunities for resiliency to be enhanced through supportive strategies (Haddadi & Besharat, 2010). Mental illness has the potential to increase feelings of anxiety, depression and distress, which may predispose someone to being more vulnerable; the provision of choice and options for decision making can help counteract these risk factors, and make a more positive impact on clients. Being involved in the feedback process of student learning enhanced clients’ self-perception of themselves towards that of a useful ‘expert citizen’ (Wilson & Fothergill, 2010, p. 35). Debyser et al. (2011) also noted the benefits of client feedback, and stated it “affects clients in a positive and meaningful way, by raising their self esteem” (p. 203).  On the heels of this conversation about resiliency and vulnerability, it is important to acknowledge the professional and cultural values embedded within the health care system, and CLIENT FEEDBACK AS A TEACHING TOOL  30 how they impact the successful transition to more engaging, client-centred models of care. Hierarchically within nursing, nursing students often view themselves as inferior and somewhat powerless (Stickley et al., 2010). These views are ironically quite similar to the views held by clients. It is in this way that students can often connect and relate well to the clients. Despite this power differential however, the students desire to align and professionally socialize with the nursing team is evident. Stickley et al. (2010) described a situation that emphasized this point quite well. In their scenario, a nursing student received critical feedback from a client, which resulted in the student dismissing it and attributing it to the client’s mental illness (Stickley et al., 2010). The student also sought out support from the clinical nursing team, who further confirmed the student’s thoughts about the client. Stickley et al. (2010) reflected on how the student’s professional identity was strengthened in this example and also how the division between ‘them’ and the client was further reinforced (Stickely et al., 2010). Although some of this tension and imbalance of power may be inevitable, it may also highlight components of the educational and professional settings that could benefit from a change (Stickley et al., 2010).  Challenges Despite the benefits of using client feedback as a teaching tool, there are concerns related to the actual or perceived vulnerable nature of both clients and students throughout these interactions. Significant time and attention within the research was directed towards not exploiting either group; however, in the process, it’s unclear if these protective mechanisms actually limited the potential of both groups. Several studies identified that students had a preference for direct feedback (Morgan and Sanggaran, 1997); however, there also was a general belief that this could be traumatic for both clients and students. Students voiced on the contrary, stating “individual comment would be so much more effective because how am I going to CLIENT FEEDBACK AS A TEACHING TOOL  31 improve if I can’t find out what patients think of me” (Morgan and Sanggaran, 1997, p. 433). Historically, formative feedback is underutilized within nursing education, which is unfortunate as it has the potential to positively influence insight and confidence levels throughout the learning experience (Koh, 2008). Waiting until the last day of a clinical rotation to provide suggestions on practice seems misplaced.   In an effort to move towards not only an educational system, but a health care system that embraces client-centered care and involvement, it is imperative we work towards practices that promote increased client engagement. Several countries are looking at ways to engage clients and carers in the decision making process (Department of Health 2009, The Healthcare Quality Strategy for NHS Scotland 2010, Australian Commission on Safety and Quality of Healthcare 2011, World Health Organization 2012, United States Medicare Patient Empowerment (MPE) Act 2015). Client roles in direct feedback to students is a very recent phenomenon, but is a trend that is anticipated to continue as shifts towards more collaborative approaches continue to grow (Haycock-Stuart, Donaghy & Darbyshire, 2016).    Nursing staff concerns about becoming demoralized from feedback was evident throughout the selected studies. Speers (2007) encountered several nurses who reflected about the vulnerabilities they faced during nursing school and their concerns with client provided feedback; alternately, the current students were more eager to develop resilience and saw value in seeking out client feedback (Speers, 2007). McMahon-Parkes et al. (2016) had similar findings, as evidenced by the nurses in their study who supported the utilization of client feedback on student nurse performance, but were more reluctant about receiving feedback about their own practice. These nurses felt there was no need for a direct solicitation of patients’ views, and that the current ‘compliments and complaints’ system was sufficient (McMahon-Parkes et CLIENT FEEDBACK AS A TEACHING TOOL  32 al., 2016). These comments illuminate the inherent power differential that is present within the health care system, and also the lack of understanding about the value of feedback being integrated into the care environment, instead of being viewed as a separate activity. Rather than academic teachers and health professionals focusing on sheltering students from the realities of the clinical setting, this energy may be better directed towards mentoring them in developing skills about reflection and coping. Such an approach may indirectly assist students in the transition from nursing school to the realities of the clinical setting when that time comes. Stickley et al. (2010) uncovered that the successful incorporation of client feedback was largely dependent on a positive valuation of students on an institutional and professional level.  Similar to the concerns about student involvement, there was also concern over the vulnerability of clients being involved in the provision of feedback and the risk of them feeling coerced to participate. However, clients not only noted their desire to participate, but also expressed feeling a strong obligation to ensure feedback was honest and authentic (McMahon-Parkes et al., 2016). Providing training opportunities and enhancing advocacy skills are two ways to empower their voice and enhance their level of trust in the health care system. Changes  The transition required to empower nursing students to become more comfortable asking for feedback instead of giving it is a significant change in practice (Speers & Lathlean, 2015). Students, and health care workers in general, are trained to be the professionals, and to share their assessments and perspectives, so navigating a health care system in which the client’s opinion is emphasized requires more than simply student acknowledgement of this importance. The health care system must adapt and revise its ways of being, and begin to truly walk the walk in regards to the ‘client as expert’ concept. This viewpoint was echoed in the selected studies. CLIENT FEEDBACK AS A TEACHING TOOL  33 Client feedback can no longer be viewed as an ‘add-on’ or something that occurs periodically (Masters & Forrest, 2010). Then, and only then, will the risk of tokenistic client involvement be minimized (Masters & Forrest, 2010; Speers, 2007).  A common consensus within the mental health setting is that students learn from clients rather than with (Rush, 2008). This messaging has influenced the clinical settings in which the students are entering, so it is no wonder that the comfort level with feedback from clients may be foreign to not only students, but staff and clients alike. Roberts (2010) spoke about the microfascism that influences the culture of mental health services, and how the language, attitudes and gestures of staff significantly impact a client’s perception of self. Engaging clients in student learning by means of inviting their feedback may counter such power inequities by leveling the perceived hierarchy (Speers & Lathlean, 2015).   As identified within Chapter 1, the social work field has led the way in not only involving clients in providing feedback to students, but also in researching and evaluating such involvement (Cuming & Wilkins, 2000; Masters & Forrest, 2010). This may be due in large part to the fact that within many countries it is now mandatory that clients be involved in all aspects of the social work education program (Department of Health, 2002). Within the United Kingdom in 2003, the Department of Health (DH) made it mandatory for clients, as well as their carers, to be involved in the design and delivery of all aspects of social work education. This included provision of feedback, but also training of clients and carers about their roles, and compensation for involvement to name a few. Analyzing client and carer engagement at a system wide level is far beyond the focus of this paper; however, an understanding of this larger goal does validate and support the idea of clients providing feedback to nursing students. It is of value to note that the concept of carer involvement in feedback did not arise within the nursing literature that was CLIENT FEEDBACK AS A TEACHING TOOL  34 reviewed, but is certainly an important variable to consider. Carers are defined as someone who provides support to a person with mental health challenges, such as a relative, partner, friend or neighbor (Levin, 2004).   This chapter presented the findings from the literature review by addressing the key concepts gleaned from the research. Gathering feedback from clients on nursing students in a formal and consistent manner is not common practice; however, the benefits of using such an approach is evident (Debyser et al., 2011). For one, “client feedback can reinforce the holistic perspective on nursing and can contribute to enhancing communication with all parties involved in an open and authentic way” (Debyser et al., 2010, p. 203). The following, last, chapter will present the conclusion and recommendations for this work moving forward.   CLIENT FEEDBACK AS A TEACHING TOOL  35 CHAPTER 4: CONCLUSION AND RECOMMENDATIONS   This integrative review has illuminated several key findings, which are important to consider in the advancement of research on client feedback on student learning in the clinical setting. Although some findings differed from study to study, something that was consistent throughout is that client feedback has the potential to make a positive impact on not only the clients giving it, but the students and health care system receiving it. Meeting clients where they are at, and valuing their voice is a critical step in developing engaging, client-centered care and programming, as well as in modelling to health care professionals of the future what truly matters in client-centered care. This chapter will summarize the findings, while also providing several recommendations for ways to enhance or expand client feedback in student learning.   At the outset of this review there was a discussion about the evolution of health care over the past 40 plus years, with a specific focus on the mental health system. An appreciation of client-centered care and the value of feedback was emphasized. As already noted on several occasions, the topic of client feedback to nursing students as a teaching tool in mental health placements is not well understood. This review sought to uncover how this very feedback has been integrated and utilized for nursing students in the mental health realm specifically. The nature of client participation, set up of feedback, stakeholders in learning, and impact of feedback was also explored.   The ten articles within this review all offered several recommendations for work in this area moving forward. These recommendations will now be discussed in greater detail below. Revision of Placement Structures  A revision of current student placement structures is one way that the feedback relationships between students and clients could be enhanced. For example, using clinical CLIENT FEEDBACK AS A TEACHING TOOL  36 placements that focus on following client pathways, rather than particular settings, may allow the relationships between students and clients to grow more gradually (Masters & Forrest, 2010). An added benefit of this organization is that the students’ exposure to the transitions in care may enhance their understanding of how the system works together, rather than viewing sites as separate entities (Masters & Forrest, 2010). Language  Stickley et al. (2010) emphasized the impact of language, and concluded that the client title is an important variable to consider in any future studies regarding client feedback. They recommend that the phrase ‘client review’ be used in place of ‘client assessment’ (Stickley et al., 2010). The purpose of this is to reduce any possible intimidation or discomfort clients and students may feel regarding the assessment label.  Simulation  The use of the simulation environment for clients to provide feedback to students is gaining momentum. Not only does the simulation setting allow volunteer clients an opportunity to provide feedback and positively contribute to the education of nursing students (Webster et al., 2012), it also impacts students in a positive manner by improving confidence levels and insight (Schwindt & McNelis, 2015). We are encouraged to continue integrating simulation into nursing student curricula as a way to “facilitate the development of students’ professional competency and to advance the science of nursing education” (Schwindt & McNelis, 2015, p. 327). Client volunteers in the simulation environment are a very valuable resource because they have first hand experience of receiving care (Webster et al., 2012). In order to maximize their effectiveness, it is critical that the client volunteers are trained in role playing and verbal feedback because if there is insufficient knowledge on the feedback process, there is potential for CLIENT FEEDBACK AS A TEACHING TOOL  37 harmful effects (Archer, 2010). Education and Support  As just noted above, preparation for the feedback role is critical for both clients and students. Masters and Forrest (2010) emphasized that close attention to the briefing and preparation of all study participants needs to occur. This will enhance the quality of the feedback provided, and also result in the development of more reflective nurses. In their study specifically, Masters and Forrest (2010) noted that the students involved were prepared in detail about the feedback process, whereas nurse mentors received written details, and clients only received their information from the students themselves.  An additional recommendation that could support the process further is a better understanding of the role the clinical instructor plays. Particularly in situations where students have little previous clinical experience and are supervised a majority of their clinical time (Twinn, 1995). In scenarios where the students are not directly supervised, providing regular debriefing opportunities is essential. Twinn (1995) also noted that not all instructors have appropriate preparation themselves, so a consideration of their competencies and learning needs as part of supporting the use of feedback is not to be overlooked (Twinn, 1995). Archer (2010) further emphasized the need for instructor support, noting the importance of developing strategy-focused approaches for feedback, rather than a diagnostic, problem focused method. Encouraging clinical instructors to provide more write ups of their experience with using client feedback in the clinical learning experiences is one way to enhance the understanding of this concept.  Where the responsibility lies for next steps for client feedback is left to be determined. As noted above, the clinical instructor is perceived to play a key role; however, the responsibility for CLIENT FEEDBACK AS A TEACHING TOOL  38 the success of the use of feedback cannot fall solely on their shoulders. Morgan and Sanggaran (1997) state that in order for such an approach to be successful, clinical instructors need to be encouraged and supported by the clinical areas themselves to facilitate it, as professional and cultural barriers can significantly promote or hasten the process. Further research on how to incorporate this form of learning into education curricula for nursing students would also likely be of great value.  Feedback Variables  Moving forward, if client feedback is to be provided directly to students, a stance should be taken on who will deliver the feedback and how that will occur. Literature from the social work field informs us that instructors often gather client feedback via questionnaires or interviews, and then incorporate this into a student’s assessment (Cuming & Wilkins, 2000).  This approach was not utilized by the studies included in this review, but could certainly be considered moving forward. It is also important to better understand clients’ views on direct, individual feedback before making the assumption that this form of feedback could be traumatic (Morgan & Sanggaran, 1997). Carer Involvement  Carer involvement in feedback was not something that was discussed within the selected studies. In the future it is important that feedback from these individuals is sought within all health care settings, as it they can offer valuable perspectives and insights on their first hand experiences in supporting a loved one through their illness. There is real potential for carers to positively shape the caring aspect of health care, particularly the relationship components of the care provided (Haycock-Stuart et al., 2016).   CLIENT FEEDBACK AS A TEACHING TOOL  39 Summary  Most of the literature included within this review focused largely on the inpatient mental health settings, however an exploration of using feedback tools in other areas of health and social care should be considered, both for nursing students and as part of professional development for registered staff (McMahon-Parkes et al., 2016; Stickley et al., 2009). As Morgan and Sanggaran (1997) concluded: If we believe that the end-product of nurse education must meet consumer demands or needs, it follows that both educators and clinical areas must acknowledge the importance of this client-centred approach to learning. (p. 433) Engaging the clients with whom we work in a more collaborative way has the potential to enhance and improve the health care system as we know it. Feedback is a critical first step to this engagement, and is something that should be more widely applied and explored in greater depth. It is hoped that in the future this learning can be expanded to include other members of the health care team, in mental health settings and beyond.   CLIENT FEEDBACK AS A TEACHING TOOL  40 References Archer, J. C. (2010). State and the science in health professional education: effective feedback. Medical Education, 44, 101-108. doi:10.1111/j.1365-2923.2009.03546.x  Australian Commission on Safety and Quality of Healthcare (ACSQHC). (2011). 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