Following your Path

Thoughtful feedback loop: A nurse’s approach to personal and organizational improvement

As a nurse, your partnership with another in the Thoughtful Feedback Loop gives you the power to exponentially increase the rate at which you professionally and personally improve. Self-reflection is not enough. Your annual evaluation is not enough. Through the Thoughtful Feedback Loop, you will experience the joy of meaningful and dramatic continuous personal improvement on a regular basis. Additionally, and perhaps more importantly, you will influence the organizational culture in which you work, one person at a time.

Commit to improve

The Thoughtful Feedback Loop is an improvement model that starts with your commitment to continuous personal improvement. This means that you are willing and able to receive feedback regarding your behaviors on a regular basis. These behaviors may include both your interpersonal communication techniques as well as your nursing practice patterns, such as gaps in your performance of standard hand hygiene while moving within a patient’s room. As you embark on this journey, your commitment to the Thoughtful Feedback Loop will necessitate a degree of personal vulnerability as a means to accomplish your own improvement.

Find a partner

Once you have established your commitment to continuous personal improvement, the next step is for you to identify a person who is willing and able to commit to a partnership in thoughtful feedback. The identification of the right person for this role is critical to the success of the Thoughtful Feedback Loop. You must trust and respect this person. It is vital that you and your partner have a noncompetitive relationship. Ideally, your partner should be someone with excellent communication skills, both nonverbal and verbal. Both you and your partner must regularly have the opportunity to observe each other performing on the job. You may identify a person on the healthcare team, someone who may or may not be a nurse. Your partner becomes your source of clarity regarding discrete personal improvement opportunities.

Continuous personal improvement will not occur without the appropriate partner. Take the time to identify potential partners and select wisely.

Start the process

Now that you have selected your partner, and he or she has agreed to participate, it is time to start. You may find the attached one page tool of value as you practice the Thoughtful Feedback Loop for the first time.

Feedback loop


The next time you are in the presence of your partner, seek thoughtful feedback by asking, “How did I do? What could I have done better?” In the context of a trusting, noncompetitive relationship, take the time to understand and reflect on the thoughtful feedback your partner has provided. You must avoid the pitfall of defensiveness, which may be your first response to what you may perceive as negative feedback. Through your partner’s thoughtful delivery of the message, keeping in mind tone of voice, facial expression, body language, and the environmental situation, defensiveness can be mitigated. If you feel yourself becoming defensive, stop, share those feelings with your partner, and adjust your course. Defensiveness will block your potential to improve.

Apply PDSA

Once you have thoroughly understood your partner’s feedback, it is time to apply the scientific method as soon as possible. The scientific method called the Plan – Do – Study – Act Cycle (PDSA) of quality guru Dr. W. Edwards Deming is simple and straightforward. In the planning step, you and your partner formulate your hypothesis. Both of you should agree on a specific outcome you hope to achieve through the feedback regarding a behavior change.

The doing step is when you try the new behavior. This process is more successful if you have the opportunity to try the new behavior as soon as possible.

The study step is when you determine whether your hypothesis was proven true. It’s a simple yes or no at this point. If yes, then act by adopting the new behavior. Share your learning because it’s likely others have had a similar challenge. If your hypothesis was not proven true, make another plan for improvement and start the cycle again.

Don’t get discouraged if you find yourself moving through the PDSA cycle several times before you prove your hypothesis true. This is very common and to be expected. As you may have suspected, the Thoughtful Feedback Loop is never ending. There is always an opportunity to improve.

An example we can all relate to is hand hygiene. I was working with a team of nurses and other direct patient care givers, and we discovered that the concept of moving from clean to dirty while caring for a patient was not well understood. It’s documented in the infection control literature, and I have observed personally, that the appropriate hand hygiene is performed about 60% of the time in any one episode of patient care provided by nurses and other healthcare providers. To achieve a higher percentage of needed hand hygiene (and to ensure providers understood the concept of moving from clean to dirty), the members of the healthcare team decided to give and receive thoughtful feedback regarding their personal practice patterns regarding hand hygiene. Here is an example, of how this might work if you were part of the team.

Your partner has observed you while you were administering IV medications to a patient. Your partner observed several lapses in your practice of hand hygiene while performing this procedure. By the way, your partner has been trained as an expert in hand hygiene observation. Your partner provides thoughtful feedback to you in real time, stating that when you touched the side rail and silenced the monitor, you are considered “contaminated.” After touching those surfaces, you should remove your gloves, foam again, and don a new pair of gloves. Together, you formulate your hypothesis: If you do not touch “dirty surfaces” in the patient room until after you complete the IV medication administration process, you will prevent gloves from becoming contaminated during the procedure.

The partnership in the Thoughtful Feedback Loop allows this improvement to happen in real time. As you move to the next patient, your partner observes your activities during IV medication administration. Your partner gives you feedback, stating that you performed the task without any lapses in hand hygiene practices. You did not touch any dirty surfaces in the room before completing the procedure. You performed 100% of the hand hygiene opportunities during this observation. Your hypothesis was proven correct.

From today’s PDSA, you have a better understanding of where your lapses occur, and where you need to improve. It is possible and likely that others are having the same issue. After observations of others performing the same procedure, you might consider implementing a one-on-one observation and coaching process for all hands-on caregivers as part of the usual routine, starting with the unit where hospital-acquired infections are the highest.

Power of change

Nurses have the power to improve personally while changing organizational culture, one person at a time. There are approximately 3.1 – 3.6 million registered nurses in the United States. Registered nurses comprise the largest group of working professionals in the healthcare industry and for this reason, have the potential for tremendous influence on organizational culture. They also comprise the largest single component of any hospital staff. It is time to make an impact on patient safety and organizational excellence. Nurses at all levels, from senior leadership to the bedside, have an opportunity to begin by partnering in the practice of the Thoughtful Feedback Loop. The joy of experiencing meaningful and regular personal improvement is yours.

Shirley Cahill is a Senior Strategic Process Improvement Consultant in Cabin John, Maryland.

Selected references

Cherry K. Types of nonverbal communication: 8 major nonverbal behaviors. http://psychology.about.com/od/nonverbalcommunication/a/nonverbaltypes.htm. Accessed: April 6, 2013.

Chopra D. The Soul of Leadership: Unlocking Your Potential for Greatness. New York, NY: Harmony Books; 2010.

Deming WE. The New Economics, 2nd ed. Cambridge, MA: Massachusetts Institute of Technology; 1996.

Institute for Healthcare Improvement. How-to guide: Improving hand hygiene. A guide for improving practices among health care workers. . Accessed: April 6, 2013.

The Joint Commission. 2009. Measuring hand hygiene adherence: overcoming the challenges. http://www.jointcommission.org/assets/1/18/hh_monograph.pdf. Accessed: April 6, 2013.

Lencioni W. The Advantage: Why Organization Health Trumps Everything Else in Business. 1st ed. San Francisco, CA: Jossey-Bass; 2012.

Scherkenbach W. The Deming Route to Quality and Productivity. 1st ed. Washington, DC: Mercury Press; 1991.

Toussaint JS, Berry LL. The promise of Lean in health care. Mayo Clin Proc. 2013;88(1):74-82.


Letter to the Editor:

In the article by Cahill S. “Thoughtful feedback loop: a nurse’s approach to personal and organizational improvement” published in volume 8(6) in June 2014, the author made a statement that nurses must work on continuous improvement of professional skills. The “Thoughtful feedback model” was proposed as a model to be used when two nurses observe each other while performing bed-side nursing care and provide each other with constructive criticism (Cahill, 2014). There is no doubt that nurses must provide excellent nursing care at bed-side, but the question is how to implement this model on practice.

Every day nurses assume responsibility for patients by providing safe, evidence-base and efficient care. However, performing bed-side care under high level of stress, multiple distractions and fast pace of modern health care, nurses may fail to perform required procedures correctly, which could lead to negative patient outcomes. Every nursing unit must make an effort to insure nursing care is being done safely and effectively. The model proposed by Cahill (2014) seems to be an excellent tool nurses could use for checking nursing skills between yearly skills fairs. Unfortunately, the author did not elaborate how this model would work in practice. The big question is how to pair nurses providing thoughtful feedback with each other? More importantly, what needs to be done in order to ensure that thoughtful feedback is provided correctly and according to the policies and procedures of a health organization? For example, we often have new nursing staff in our nursing unit, to include new graduate RNs starting on our floor, and we always seem to run into the same problems during orientation period. More experienced nurses have hard time being oriented by nurses with less experience. For instance, one of our new employees was an LPN for 10 years; even though, she works in a new role of RN, she had hard time when provided with constrictive criticism from a staff RN with only two years of experience. Moreover, new graduate RN when oriented by multiple staff members always make comments that they observed different ways of performing nursing skills by different staff nurses.

Nurses are expected to constantly work on maintaining their clinical skills up-to-date. “Thoughtful feedback loop” model, proposed by Cahill (2014) could be used by nurses as an excellent tool for improving clinical skills. Most importantly, the model needs to be used correctly and according to polices and procedures.

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