To cite this article: Heather Leggett, John Sandars & Trudie Roberts (2019) Twelve tips on how to provide self-regulated learning (SRL) enhanced feedback on clinical performance, Medical Teacher, 41:2, 147-151, DOI: 10.1080/0142159X.2017.1407868
引用本文：Heather Leggett、John Sandars 和 Trudie Roberts（2019）提供自我調節學習（SRL）增強臨床表現反饋的十二個提示，醫學教師，41:2，147-151，DOI：10.1080/0142159X.2017.1407868

To link to this article: https://doi.org/10.1080/0142159X.2017.1407868
要連結至本文: https://doi.org/10.1080/0142159X.2017.1407868

Published online: 11 Dec 2017.
發佈日期：2017 年 12 月 11 日。

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Heather Leggett , John Sandars (D) and Trudie Roberts
Heather Leggett ，John Sandars （D）和 Trudie Roberts

Feedback is an essential aspect of medical education. By providing information to learners regarding their current performance and how it can be improved, feedback provides an opportunity for learners to progress (Ende 1983). Despite the importance of feedback, there is great variability in its effect iveness and a review of feedback across a variety of disciplines has highlighted that four components are essential: self, task, process, and self-regulated learning (Hattie and Timperley 2007). Feedback on the "self" considers the importance of providing "positive" feedback to maintain motivation. Feedback on the "task" has a focus on the extent to which a task was adequately performed, and feedback on "process" considers what knowledge or skills were used, or not used, to achieve the task. Feedback on self-regulated learning (SRL) appears to be an integral component for effective feedback and considers the self-regulation approach used by the learner as they perform the task.
反饋是醫學教育的重要方面。通過向學習者提供有關其當前表現及如何改進的信息，反饋為學習者提供了進步的機會（Ende 1983）。儘管反饋的重要性，其效果存在著很大的變異性，對各種學科領域的反饋進行審查後發現，有四個基本組成部分：自我、任務、過程和自我調節學習（Hattie 和 Timperley 2007）。關於“自我”的反饋考慮到提供“積極”的反饋以保持動機。關於“任務”的反饋著重於任務是否得到適當執行，而關於“過程”的反饋則考慮到實現任務時使用了哪些知識或技能，或者沒有使用哪些。對自我調節學習（SRL）的反饋似乎是有效反饋的一個不可或缺的組成部分，並考慮到學習者在執行任務時所使用的自我調節方法。

There are similarities between self-directed learning (SDL) and SRL, with both having a focus on developing independent learners, but SDL is a broader concept that highlights the importance of freedom of choice compared with SRL's focus on the individual learner's approach to achieving a task (Loyens et al. 2008). There is increasing interest in the use of SRL in medical education (Sandars and Cleary 2011), including its importance across a range of clinical performance situations, such as clinical skills (Cleary and Sandars 2011; Andersen et al. 2017) and making a clinical diagnosis (Artino et al. 2014; Patel et al. 2015). However, our personal experience is that feedback on the essential SRL component is rarely given or discussed in the numerous practical guides on how to provide feedback on clinical performance.
自主學習（SDL）和 SRL 之間存在相似之處，兩者都著重於培養獨立學習者，但 SDL 是一個更廣泛的概念，強調與 SRL 專注於個人學習者方法來完成任務相比，自由選擇的重要性（Loyens 等人，2008 年）。在醫學教育中使用 SRL 的興趣日益增加（Sandars 和 Cleary，2011 年），包括其在各種臨床表現情況中的重要性，如臨床技能（Cleary 和 Sandars，2011 年；Andersen 等人，2017 年）和臨床診斷（Artino 等人，2014 年；Patel 等人，2015 年）。然而，我們的個人經驗是，在如何提供臨床表現反饋的眾多實用指南中，對於基本的 SRL 組成部分的反饋很少被給予或討論。

In this 12 Tips article, we provide practical advice that is based on our experience of how to provide feedback that is enhanced with SRL components within the context of clinical skills and making a clinical diagnosis. Since the intention of SRL enhanced feedback is to build on the existing approaches that are used by medical educators, it is important that current best practice in providing feedback is also followed, such as that described by Ramani and Krackov (2012) and is kept in mind while reading these tips. An essential aspect is to ensure that feedback is given within a challenging, yet supportive relationship, between the learner and the educator (Telio et al. 2015)
在這篇 12 個提示的文章中，我們提供了實用建議，這些建議是基於我們如何在臨床技能和臨床診斷的背景下提供增強了 SRL 元素的反饋的經驗。由於 SRL 增強了反饋的意圖是建立在醫學教育工作者使用的現有方法之上，因此重要的是也要遵循目前提供反饋的最佳實踐，例如 Ramani 和 Krackov（2012）所描述的實踐，並在閱讀這些提示時牢記在心。一個重要的方面是確保在學習者和教育者之間建立具有挑戰性但支持性的關係來提供反饋（Telio 等人，2015）。

SRL is a three-phase cyclical process during which individuals proactively plan, self-monitor, and adapt their actions to ensure that their chosen goals are met (Zimmerman 2000). There is a forethought phase before any efforts to perform which involves goal setting, planning a specific strategy with a range of techniques to achieve the goal, and the mobilization of self-efficacy beliefs. This is followed by a performance phase in which the learner self-monitors the extent to which the goal is being achieved by their chosen strategy. During the third phase of self-evaluation, changes are made to the chosen strategy to ensure that the goal is achieved; also self-efficacy beliefs may need to be reinforced and attribution beliefs be challenged (Zimmerman 2000). High performers in clinical skills and diagnostic decision making make greater use of a SRL approach, whereas low performers are less likely to employ a SRL approach (Cleary and Sandars 2011; Artino et al. 2014). Importantly, learners can be trained to improve their SRL, and this has been shown to lead to improvement in their performance (Sitzmann and Ely 2011). Consequently, feedback on a learners' SRL, which helps them to become more self-regulated, is a valuable tool for educators wanting to provide more meaningful and individualized feedback (Durning et al. 2011).
SRL 是一個三階段的循環過程，個人在此期間會主動計劃、自我監控並調整他們的行動，以確保他們選定的目標得以實現（Zimmerman 2000）。在進行任何努力之前，有一個先見之明的階段，其中包括目標設定、規劃具體策略以及使用各種技巧來實現目標，以及自我效能信念的動員。接著是表現階段，在這個階段中，學習者通過自我監控來評估他們選定策略實現目標的程度。在自我評估的第三階段，將對選定的策略進行修改以確保實現目標；同時可能需要加強自我效能信念並挑戰歸因信念（Zimmerman 2000）。在臨床技能和診斷決策方面，高表現者更多地採用 SRL 方法，而低表現者則不太可能採用 SRL 方法（Cleary 和 Sandars 2011；Artino 等，2014）。重要的是，學習者可以接受培訓以改善他們的 SRL，這已被證明可以提高他們的表現（Sitzmann 和 Ely 2011）。 因此，對學習者的自主學習反饋是一個有價值的工具，可以幫助他們變得更加自主調節，對於希望提供更有意義和個性化反饋的教育工作者而言（Durning 等，2011 年）。

Providing SRL enhanced feedback requires the identification of the SRL approach being used by the learner.
提供 SRL 增強反饋需要識別學習者正在使用的 SRL 方法。

Research which has used SRL to assess and improve performance has successfully utilized a microanalytic framework to distinguish between high and low performers (Cleary et al. 2012). Microanalysis adapts the use of "thinkaloud protocols" and real-time observation to assess learner's SRL approach during or immediately after a specific task, with targeted questions related to the forethought, performance, and self-evaluation phases. This is advantageous, since it can assess thought processes and actions taken while the event is still underway rather than after the event. Consequently, more specific and detailed feedback can be given to the learner based on their responses.
使用 SRL 來評估和改善表現的研究已成功地利用微分析框架來區分高低表現者（Cleary 等人，2012）。微分析適應了“思考出聲協議”和實時觀察的使用，以評估學習者在特定任務期間或之後立即採取的 SRL 方法，並提出針對前瞻、表現和自我評估階段的問題。這是有利的，因為它可以評估事件仍在進行時採取的思考過程和行動，而不是在事件之後。因此，可以根據學習者的回應給予更具體和詳細的反饋。

The questions should be structured to elicit the key SRL components within each phase of the SRL cycle. These components will be discussed in Tips 3-9. Examples of microanalytic questions and their timing to inform feedback are outlined in Tip 10.
問題應該設計成在每個自主學習循環階段內引出關鍵的自主學習組成部分。這些組成部分將在提示 3-9 中討論。微觀分析問題的例子及其時機以提供回饋在提示 10 中概述。

Self-efficacy is the extent to which an individual feels confident about whether they can achieve a task (Zimmerman 2000) but also how receptive and responsive they are to feedback (Dweck and Leggett 1988). For example, an under-confident learner is less likely to believe in their ability to improve, whereas an over-confident learner is less likely to recognize when they have underperformed and not attribute this to their own skills (Hadwin and Webster 2013). Understanding and correctly identifying and conveying student's self-efficacy and confidence back to them will facilitate students in creating their own accurate self evaluation of their own performance. Identification of the learner's beliefs about their self-efficacy can help the educator to focus their feedback to ensure that under-confident or over-confident learners begin to appreciate that their performance is related to their own skills and not attribute their performance to luck or other factors outside of their control. The importance of attribution beliefs is further discussed in Tip 8.
自我效能是指個人對於自己能否完成任務感到自信的程度（Zimmerman 2000），同時也涉及個人對於反饋的接受和回應程度（Dweck 和 Leggett 1988）。例如，缺乏信心的學習者不太可能相信自己有改進的能力，而過於自信的學習者則不太可能意識到自己表現不佳，並不會將這歸因於自己的技能（Hadwin 和 Webster 2013）。了解並正確識別和傳達學生的自我效能和信心將有助於學生創建對自己表現的準確自我評估。確定學習者對於自我效能的信念，有助於教育工作者將注意力集中在反饋上，確保缺乏信心或過於自信的學習者開始意識到他們的表現與自身技能有關，並不將表現歸因於運氣或其他無法控制的因素。歸因信念的重要性在 Tip 8 中進一步討論。

The goals that the learner sets are fundamental to the performance of a task, whether a clinical skill or making a clinical diagnosis. Learners who set clear and specific goals before performing a task which are focused on the steps procedures, or strategies required to complete the task have higher levels of performance, and can learn more effectively from past performances (Cleary and Zimmerman 2001; Cleary and Sandars 2011). In contrast, those who do not set clear and specific goals are more likely to focus only on the end outcome of the task. For example, the goals of a good self-regulated learner preparing to take blood from a patient would be to "go through the procedure in my head, step by step, before I actually do it ... try to have a plan of action in my mind", whereas a poor selfregulated learner's goal will simply be to take blood (Cleary and Sandars 2011, p. e371). Feedback should have a focus on how clear and specific the learner's goal setting is and encourage them to set appropriately challenging, relevant, process focused, and specific goals.
學習者設定的目標對於執行任務至關重要，無論是臨床技能還是臨床診斷。在執行任務之前設定清晰具體的目標，專注於完成任務所需的步驟、程序或策略的學習者，表現水平較高，並能更有效地從過去的表現中學習（Cleary 和 Zimmerman 2001; Cleary 和 Sandars 2011）。相反，那些沒有設定清晰具體目標的人更有可能僅專注於任務的最終結果。例如，一個良好的自我調節學習者準備從患者身上抽血的目標將是“在實際執行之前，逐步在腦海中過一遍程序...試著在腦海中制定行動計劃”，而一個自我調節能力較差的學習者的目標只是抽血（Cleary 和 Sandars 2011, p. e371）。反饋應該專注於學習者目標設定的清晰程度和具體性，並鼓勵他們設定具有挑戰性、相關性、過程導向和具體性的目標。

High performing learners engage in strategic planning before they begin a task, with a range of clearly defined specific techniques that they believe will lead to successful achievement of the goal set in response to the task (Cleary and Zimmerman 2001; Sandars and Cleary 2011). Thinking in terms of specific strategies or techniques, such as the detailed procedure of taking a blood sample, auscultation of the heart or taking a cardiac history, will help learners to monitor and regulate their progression through the task and make adaptive changes to keep on track or to improve in future tasks. Feedback should encourage learners to "think strategically", with a clear and specific strategy or technique that is set before, self-monitored during, and reflected upon after clinical performance.
高效學習者在開始任務之前會進行戰略規劃，擁有一系列清晰定義的特定技巧，他們相信這些技巧將有助於成功實現任務中設定的目標（Cleary 和 Zimmerman 2001; Sandars 和 Cleary 2011）。以具體策略或技巧來思考，例如進行抽血樣本的詳細程序、聽心音或採集心臟病史，將有助於學習者監控和調節他們在任務中的進展，並進行適應性變化以保持在正軌上或在未來任務中改進。反饋應該鼓勵學習者“戰略性思考”，在臨床表現之前設定明確和具體的策略或技巧，並在自我監控期間進行反思。

High performing learners are more likely to actively adapt or change their chosen strategy or technique throughout the task by using self-monitoring to increase their awareness of their progress towards achieving their intended goals (Sandars and Cleary 2011). Without developing selfmonitoring, the learner cannot dynamically change their performance to the demands of a task that is evolving, such as when there is an unexpected and unusual physical sign or response to a clinical enquiry question. Interestingly, structured reflection during the making of clinical diagnoses appears to improve learners' diagnostic competence by fostering the restructuring of their existing medical knowledge about the diagnosis and associated diseases (Mamede et al. 2012). SRL enhanced feedback should focus on assessing the learner's self-monitoring and provide them with feedback to ensure that this essential component of SRL is utilized during their performance.
高效學習者更有可能通過使用自我監控來增加對實現預期目標進展的意識，積極適應或改變他們在任務中選擇的策略或技巧（Sandars 和 Cleary 2011）。如果沒有發展自我監控，學習者無法動態地改變他們的表現以應對正在發展的任務的需求，例如在對臨床詢問問題的意外和不尋常的身體徵兆或反應時。有趣的是，在進行臨床診斷時進行結構化反思似乎可以通過促進對診斷和相關疾病的現有醫學知識進行重組來提高學習者的診斷能力（Mamede 等，2012）。自主學習增強反饋應該專注於評估學習者的自我監控並向他們提供反饋，以確保這種自主學習的基本組成部分在他們的表現過程中得到利用。

Self-evaluation with reflection on performance assists the learner in creating their own internal SRL feedback so that they can begin to calibrate and adjust their performance to the varying demands of a task (Butler and Winne 1995; Hattie and Timperley 2007). Furthermore, learner self-reflection prior to feedback may improve how well the feedback is received (Pelgrim et al. 2013), and reflection after feedback may also influence later use of that feedback (Sargeant et al. 2009). Feedback should incorporate a focus on encouraging the learner to self-evaluate and reflect on their performance after the task, both before and after they have been given feedback. This could include allocating time for reflection, using a reflective log or asking the learner direct questions about their reflection and asking
自我評估並反思表現有助於學習者創建自己內部的自我調節反饋，使他們能夠開始校準和調整其表現以應對任務的不同需求（Butler 和 Winne 1995; Hattie 和 Timperley 2007）。此外，學習者在獲得反饋之前進行自我反思可能會提高反饋的接受程度（Pelgrim 等人 2013 年），而在獲得反饋後進行反思也可能影響對該反饋的後續使用（Sargeant 等人 2009 年）。反饋應該著重鼓勵學習者在任務之後自我評估和反思，無論在他們獲得反饋之前還是之後。這可能包括分配時間進行反思，使用反思日誌或直接向學習者提問有關他們反思的問題。

them to create an action plan based on their reflection and feedback.
讓他們根據他們的反思和反饋來制定行動計劃。

Attribution beliefs are the learners' specific beliefs about the causes of their performance, with high performers being more likely to consider that the cause of their performance is controlled by themselves and low performers being more likely to consider that their performance is influenced by factors outside of their control (Graham and Weiner 1996). Such attributions are adaptive since they enhance learner's self-efficacy beliefs to improve their performance (Bandura 1997), and will also re-direct learner's attention back onto focusing on the strategic planning required to complete the task (see Tip 5); an effective focus on strategic planning is key to successful task performance (Cleary et al. 2006). Feedback should facilitate learners to recognize their mistakes and attribute them to a strategy they can modify for future learning and performance, instead of blaming factors outside of their control that they cannot modify, such as "the wrong type of patient" (Sandars and Cleary 2011).
歸因信念是學習者對其表現原因的具體信念，高表現者更有可能認為其表現的原因受到自身控制，而低表現者更有可能認為其表現受到自身控制之外的因素影響（Graham 和 Weiner，1996）。這些歸因是適應性的，因為它們增強了學習者改善表現的自我效能信念（Bandura，1997），並且還會將學習者的注意力重新集中在完成任務所需的戰略規劃上（參見提示 5）；有效的戰略規劃焦點是成功任務表現的關鍵（Cleary 等，2006）。反饋應該幫助學習者認識到自己的錯誤並將其歸因於他們可以為未來學習和表現修改的策略，而不是歸咎於他們無法修改的控制之外的因素，如“錯誤類型的患者”（Sandars 和 Cleary，2011）。

Adaptive changes to the chosen strategy or techniques improve the learner's performance and are dependent on having strategic attribution beliefs (Kitsantas and Zimmerman 2002). These individuals are more likely to recognize the need for adaptive changes to the strategy employed during or after the task. Learners who make strategic attributions are more likely to make strategic adaptive changes and to modify their strategy in future tasks (Cleary et al. 2006; Sandars and Cleary 2011). Ultimately, these learners are more likely to be able to adjust their approach during real time tasks in order to improve their performance. Feedback should encourage learners to make adaptive changes to their chosen strategy after poor performance.
適應性改變所選策略或技巧可提升學習者的表現，並取決於具有策略歸因信念（Kitsantas 和 Zimmerman 2002）。這些個體更有可能認識到在任務期間或之後需要對所採用的策略進行適應性改變。做出策略歸因的學習者更有可能進行策略性的適應性改變，並在未來任務中修改他們的策略（Cleary 等人，2006 年；Sandars 和 Cleary，2011 年）。最終，這些學習者更有可能能夠在實時任務中調整他們的方法，以提高表現。反饋應該鼓勵學習者在表現不佳後對所選策略進行適應性改變。

Tips 3-9 highlight feedback around the important components of the SRL process. The components are interdependent and an essential skill for the educator is the integration into a coherent whole. Table 1 illustrates how SRL enhanced feedback on making a diagnosis can be provided and aligned with key SRL processes using the timing of relevant focused questions. It is important to note that the microanalytic questions do need to be tailored to the specific task at hand.
提示 3-9 強調了關於 SRL 過程重要組成部分的反饋。這些組成部分相互依存，對於教育工作者來說，整合成一個連貫的整體是一項基本技能。表 1 說明了如何通過提出相關的專注問題的時間來提供增強診斷方面的 SRL 反饋，並與關鍵的 SRL 過程對齊。重要的是要注意，微觀分析問題確實需要根據手頭的具體任務進行定制。

Initially, educators may find that providing SRL enhanced feedback is time consuming but we have found that educators can begin to quickly adapt the SRL questions to their usual feedback approach through repeated practice. One dilemma educators may face is the identification of the learner's self-efficacy, goal setting, planning, and selfmonitoring before and during a real-life encounter with a patient in a clinical setting. It is not always appropriate to interrupt a clinical task when a patient is present in order to ask the learner a question. Our experience suggests that this can be overcome by the learner writing down the answers to the pre-performance questions before the clinical encounter or by the educator asking the questions immediately after the encounter.
最初，教育工作者可能會發現提供自主學習增強反饋是耗時的，但我們發現教育工作者可以通過反复練習迅速適應自主學習問題，將其融入到他們通常的反饋方式中。教育工作者可能面臨的一個困境是在臨床環境中在真實病人面前確定學習者的自我效能、目標設定、計劃和自我監控。在病人在場時打斷臨床任務以向學習者提問並不總是合適的。我們的經驗表明，這可以通過學習者在臨床遭遇之前寫下對於表現前問題的答案，或者通過教育工作者在遭遇之後立即提問來克服。

It is essential that feedback on SRL is provided within current "best practice" and with feedback on the self, task, and process components which are required for effective feedback. This integrated approach to feedback is the key feature of SRL enhanced feedback. Feedback given to a learner should be nonjudgmental towards that learner as an individual (not influenced by personal feelings toward the learner), reinforce positive actions, guide future practice by identifying areas for improvement (Gigante et al. 2011), and be negotiated between the educator and the learner (Telio et al. 2015). The previous 12 Tips articles by Ramani and Krackov (2012) and van der Leeuw and Slootweg (2013) offer useful advice in providing "best practice" feedback. In the context of feedback on clinical skills or making a clinical diagnosis, specific information on technique, such as correct placement of the needle for taking blood or stethoscope on the chest for auscultation of the heart, or factual information, such as the multiple causes of shortness of breath, is likely to be required also.
在提供有關自主學習的反饋時，必須遵循當前的“最佳實踐”，並提供有關自我、任務和流程組成部分的反饋，這些是有效反饋所必需的。這種整合式的反饋方法是增強自主學習反饋的關鍵特徵。應向學習者提供的反饋應該不對該學習者作為個人進行評判（不受對該學習者的個人感情影響），強化積極行為，通過確定改進領域來引導未來的實踐（Gigante 等，2011 年），並應在教育者和學習者之間進行協商（Telio 等，2015 年）。 Ramani 和 Krackov（2012 年）以及 van der Leeuw 和 Slootweg（2013 年）之前的 12 條提示文章提供了在提供“最佳實踐”反饋方面的有用建議。在臨床技能或進行臨床診斷的反饋背景下，還可能需要有關技術的具體信息，例如正確放置採血針或聽診心臟時將聽診器放在胸部的技巧，或者有關呼吸急促的多種原因的事實信息。

The provision of SRL enhanced feedback requires identification of the key SRL processes but this needs to be integrated with best practice for giving feedback. We consider that SRL enhanced feedback offers an essential opportunity to improve the effectiveness of feedback on clinical skills and making a clinical diagnosis. In addition, SRL enhanced feedback can develop the essential SRL skills required for self-directed and life-long learning.
提供 SRL 增強型反饋需要識別關鍵的 SRL 過程，但這需要與最佳的反饋實踐相結合。我們認為 SRL 增強型反饋提供了一個重要機會，可以提高臨床技能和臨床診斷反饋的效果。此外，SRL 增強型反饋可以培養自主學習和終身學習所需的基本 SRL 技能。

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
作者報告沒有利益衝突。作者獨自負責本文的內容和撰寫。

Heather Leggett, Msc, PhD, is a research fellow at the University of Leeds. Her interests are in the use of self-regulated learning to identify and improve performance.
Heather Leggett, Msc, PhD, 是利茲大學的研究員。她的興趣在於利用自我調節學習來識別和改善表現。

John Sandars, MSc, MD, MRCP, MRCGP, FAcadMEd, is a Professor of Medical Education in the Postgraduate Medical Institute at Edge Hill University and has a research and development interest in enhancing professional performance, especially with the use of self-regulated learning.
約翰·桑達斯（John Sandars），MSc，MD，MRCP，MRCGP，FAcadMEd，是埃奇希爾大學（Edge Hill University）研究生醫學院（Postgraduate Medical Institute）的醫學教育教授，專注於提升專業表現，特別是自主學習的應用。

Trudie Roberts, BSc (Hons) MBChB, PhD, FRCP, FHEA, is a Professor of Medical Education and Director at Leeds Institute of Medical Education, University of Leeds, UK
Trudie Roberts, BSc（榮譽）MBChB，博士，FRCP，FHEA，是英國利茲大學醫學教育學教授兼主任

Heather Leggett (iD http://orcid.org/0000-0001-8708-9842
Heather Leggett（iD http://orcid.org/0000-0001-8708-9842

John Sandars (ID http://orcid.org/0000-0003-3930-387X
約翰·桑達斯（ID http://orcid.org/0000-0003-3930-387X

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