By Shahina Braganza (@ShahinaBraganza), Demian Szyld (@debriefmentor), Jenny Rudolph (@GetCuriousNow) and the Gold Coast Hospital EDGE Collaborators [EDGE is “Educators Get Educated”, and is the community of practice and fellowship led by Victoria Brazil, and formed by the educators at Gold Coast Hospital Emergency Department.]
“Hey, good job on that teaching session this morning!”
Many clinicians, healthcare educators, and managers strive to hold good quality feedback conversations. Usually we struggle with how to critique others in a constructive way without hurting their feelings. Often lost in the shuffle is expressing meaningful appreciation, admiration, or positive regard of any sort. When we do say something positive, it’s brief: “Good job!” “Way to go!” “Well done”. The problem with most positive feedback is that it doesn’t actually improve performance or relationships because it is too vague.
Education researchers Bob Kegan and Lisa Lahey* argue that expressing positive regard for others in our everyday life, frequently – not waiting for someone to die to say what we valued about them in a eulogy – can be transformative for the connections, meaning, and the learning it imparts. Regularly expressing positive regard—our appreciation or admiration for the impact someone else’s actions have had on us—is what they term “on-going regard.” On-going regard is about noticing someone’s action, recognizing its impact on us, and describing the impact of their action on us. It is about being more direct and less implicit about our appreciation and admiration.
But doing this: expressing on-going regard directly, can be surprisingly difficult.
In this blog post, we build on Kegan and Lahey’s work by illuminating the “micro-skills” behind on-going regard, and providing a “how to” – giving some examples from our own work.
But first, why bother with expressing on-going regard? Building on-going regard into everyday work life can change the tenor of work groups to enhance connection (“Wow, you actually care about me!”) and support risk-taking in the service of learning (“Hey, someone noticed that I tried something new!”). It takes courage to try new things, and a sense of psychological safety to be willing to do so; having a safety net of positive regard can help. In creating a community of peers and mentors aiming at incremental improvement, on-going regard can make it easier to “get better at getting better.”
Imagine rarely or never receiving positive reinforcement from a teacher, coach, colleague, or boss. The absence of explicit positive regard can range from difficult, “They don’t like me!” to painful “I’m no good!” to confusing “Did anyone notice what I did?” or “Was it any good?”
Positive regard and learning
The paradox is that while we often think to help others learn by critiquing and correcting their performance, most of us systematically undervalue the importance of positive feedback in sustaining and informing performance. Sharing the positive impact on us of other people’s actions in a specific and direct way helps them (and us) learn what is effective.
Situation: A medical student did a patient assessment and notes for me (a resident) during an emergency shift.
Direct praise: Oh thanks – good stuff, that’s really helpful (followed by immediately walking off).
Impact on me/on-going regard: Thanks for your patient review and notes! It was thorough and has painted a really good history of this kid’s presentation.
Positive regard and connection
But the value of being valued goes beyond learning and can be effective in enhancing connection. When someone tells me how they appreciate or admire something I have done, and shares their experience of it, I learn about my impact on them, and, through this, I also see them more clearly. This is a form of intimacy, based on trust and mutual respect, that can strengthen positive interdependence.
Situation: V (doctor) introduced an Emergency department pause/mindfulness moment really well.
Direct praise: That was a great pause moment set up!
Impact on me/on-going regard: The way you introduced the mindfulness moment made me feel connected to how you value being a good doctor and how you strive to be better; it also helped me see how “being real” can really connect with others in the audience.
Positive regard and meaning
Sharing and hearing about the positive impact we have on each other infuses meaning into our busy, usually transactional, get-it-done lives. Finding out that something I did or said had a positive impact on someone can make my everyday actions feel more worthwhile. And when I share the positive impact someone had on me, that appreciation or admiration tilts me into a positive emotional state that can lift me – and them – up.
Situation: J (Medical Education Officer) came to the seminar even though she wasn’t feeling that well.
Direct praise: J, you are fabulous for coming to the seminar when you didn’t feel that well.
Impact on me/on-doing regard: When you came to the seminar despite feeling sick, I felt as though you understood how important this was to me.
Building connection and meaning strengthens the psychological safety net among us. It sets the tone for our team dynamics with respect to our sense of trust: that our team-mates are not just competent but are willing to work in harmony with us to effect positive outcomes. One key consideration is that this safety net is best created prior to a critical event, rather than in the midst of it. An elegant clinical analogy is the process of pre-oxygenating the patient prior to intubation – it creates a buffer, a cushion, that mitigates against challenges that may arise.
Micro-skills of conveying positive regard
Kegan and Lahey advocate that positive regard be direct, specific, and describe the impact on the feedback-giver (they call this “non-attributive”). This requires a set of micro-skills involving self-awareness, observation, and verbal expression that some of us may find challenging. It may be helpful to consider the concept of emotional granularity whereby the feedback-giver is able to pay attention to, and identify in “high resolution”, not only the task impact of the act but the emotional impact experienced by them. This level of intimacy may cause discomfort to some of us, particularly if we are not culturally or personally wired to recognize or express a broad or deep spectrum of emotion. We suggest that overcoming this discomfort takes some concerted practice, and may start with first working on describing task impact, and gradually titrating up to emotional impact.
We’ve put together a table that outlines the skill, and then suggests how it may be practised and developed.
Summary – Building skill at ongoing regard that is direct, specific, and shares the impact
For most of us, it is a knee-jerk reaction to say, “Great job!” or “They went the extra mile!” in a way that makes attributions about the other person’s performance – and often about them. It is automatic. In order to develop the skill of expressing ongoing regard, pay attention to when you are giving a feedback comment, try to “catch” yourself doing it the old way (brief, non-specific, and stopping short of the impact on you), and then look for an opportunity to 1) identify the specifics of the action; 2) recognize its impact on you; and 3), express both of these directly to the person. This builds the new skill.
In doing so, you may discover that your original comment “Hey, good job on that teaching session this morning” evolves into “Thanks for helping me with the teaching session. I felt so much more confident and supported having you there because I think you help me fill the gap of not being a clinician – by giving real-life stories and examples. I saw how you connected with the doctors as a medical colleague: I could see they really felt understood by you”.
So our challenge to you is: when you appreciate or admire what someone has done this coming week, pause for a moment to recognize that this is what you appreciate or admire, and try to incorporate the ideas of speaking directly to them, being specific, and adding the element of how their actions impacted upon you. Then, reflect upon whether there was added value to sharing positive feedback or on-going regard.
*See: Robert Kegan and Lisa Lahey, “From the language of prizes and praising to the language of on-going regard”. In: How the Way We Talk Can Change the Way We Work.” San Francisco: Jossey-Bass; 2001: 91-102.
About the authors:
Shahina Braganza, Department of Emergency Medicine at the Gold Coast University Hospital, and Bond University Faculty of Health Sciences and Medicine; Demian Szyld, Center for Medical Simulation, Harvard Medical School, and Department of Emergency Medicine at the Brigham Women’s Hospital; Jenny Rudolph, Center for Medical Simulation, Harvard Medical School and Department of Anesthesia, Critical Care and Pain Medicine at the Massachusetts General Hospital, as well as the Gold Coast Hospital EDGE Collaborators.
GCH EDGE Collaborators: Jessica Young, Brooke Bullock, Sarah McNamee, Dwain Burridge, Belinda Lowe, David Lawless, Chris Speirs, Nemat Alsaba, Karanjot Lall, Kristian Krogh, Monique Hare and Victoria Brazil.
