Feedback is defined as a process through which learners make sense of information from various sources and use it to enhance their work or learning strategies (Carless, 2015). Providing learners with feedback is an integral part of teaching and can have a powerful influence on student learning (Dowden et al, 2013). On midwifery programmes, feedback is continuous from practice supervisors and assessors (Nursing and Midwifery Council (NMC), 2023a), service users in clinical practice and theoretical assessments marked by academic educators. Feedback from practice experiences is often verbal, with accompanying written text from practice supervisors and service users in their midwifery ongoing record of achievement. Feedback from theoretical assessments includes formative and summative feedback, but this project focused on feedback for summative assessments.
There is a wide range of evidence from the national student surveys that suggests feedback is often rated lower than other aspects of teaching and learning (Killingback et al, 2019). Feedback is a critical component of the learning process, providing learners with valuable insights into their performance, identifying areas for improvement and promoting reflective practice. However, traditional methods of delivering feedback, such as written comments and face-to-face group discussions, often lack engagement and specificity, and may not effectively support learners in understanding and applying feedback to enhance their learning (Henderson et al, 2019). These methods can also be time consuming for lecturers and impersonal for the student.
The purpose of feedback is to enable the student to progress, meet the programme learning outcomes and ultimately to be a safe and competent practitioner in midwifery (NMC, 2019; 2023b). Assessments should be designed throughout the programme to provide regular insight into student progression in both theory and clinical practice (NMC, 2023b). The transition through healthcare degree programmes is complex (Matheson et al, 2018). As a result of concerns over shortages in the midwifery workforce (Royal College of Midwives (RCM), 2023a), it is imperative that midwifery students are supported to complete their course on time to join the maternity workforce.
Attrition from midwifery programmes is hard to ascertain; however, prior to the pandemic, Lovegrove (2018) reported that midwifery attrition averaged around 13.6% and that there was increasing improvement in retention trends between 2009 and 2015. Current data indicate that around a third of healthcare students (including midwifery) want to leave their course in England (NHS England, 2023). Financial hardship while studying (RCM, 2024) and course workload (Hamshire et al, 2019; NHS England, 2023) are significant challenges for student midwives. These factors are noteworthy, as feedback provides insight for the student on their progress (Yorke, 2001). Unhelpful feedback that is not encouraging and predominantly negative may also cause emotional distress for the learner (Paterson et al, 2020). If feedback is demotivating and not helpful, this may contribute to future failure (Race, 2020), further distress and even withdrawal from the course (Ajjawi et al, 2020).
Traditionally, feedback for summative essays in midwifery education is provided in a written format. Individual feedback is provided by in text comments and then an overall summary linking the grade to a marking rubric (Chan and Ho, 2019). Feedforward points help learners to improve on future work (Race, 2020). Effective and engaging assessment feedback is essential for the professional development and academic success of midwifery learners (Race, 2020).
The integration of digital health technologies in feedback delivery offers innovative solutions to enhance learner engagement, making the feedback process more interactive, personalised and effective (Pinto and Leite 2020). ‘Digital health technologies’ refer to the use of digital tools and platforms to deliver assessment feedback in a manner that enhances engagement, personalisation and efficiency. These technologies can include learning management systems, such as Blackboard, Moodle or Canvas, that allow educators to provide feedback on assignments, quizzes and other assessments digitally (Turnbull et al, 2020). These systems can offer various forms of feedback, including written comments, audio recordings and video feedback.
Rationale
The benefits, challenges and future implications of using digital health technologies to enhance assessment feedback in midwifery education were explored as part of an evaluation of a new communication strategy implemented in a midwifery programme in northwest England. Learners often report dissatisfaction with written feedback (Deeley et al, 2019) stating concerns with content and ambiguous and unclear comments. Timeliness is also a contentious issue with learners, who have stated that feedback often occurs too late in a project to be used (Race, 2020). Feedback is made available when the assignment has been marked but learners often do not look back and use the feedback in a meaningful way (Henderson et al, 2019). This traditional method of providing written feedback to assessment is also viewed as a laborious task by assessors, increasing workload in an already challenging and demanding profession (Myyry et al, 2020). This is compounded as cohort sizes have increased to meet future workforce needs (NHS England, 2023b).
Methods
Verbal feedback was implemented for learner midwives using the Blackboard virtual learning environment to enhance learning and feed forward. The students had previously received written feedback for past theoretical assessments. The aim of the evaluation was to explore the use of verbal feedback to improve engagement, which was then assessed via an evaluation.
Participants
In 2019, an unpublished pilot study was performed to trial the use of audio feedback to a cohort of 66 learner midwives undertaking a written assessment related to public health. The results suggested that further exploration of this method of assessment would be beneficial. In 2022, audio feedback was used for assessments with two cohorts of learner midwives (n=129), all of whom were invited to complete the evaluation questionnaire.
Implementing verbal feedback
The project focused on verbal feedback for a summative assessment. The authors were keen to explore an innovative method to support and inform learners in academia while promoting the use of new technology. Digital technologies are increasingly used in the NHS (2019) to communicate with service users; however, Morris et al (2023) found that the healthcare workforce did not have the digital capability to support digital transformation. This method of receiving and internalising feedback has the potential to support learners in their experience of using digital technologies in their clinical practice.
The two assessments for which verbal feedback was provided were 1500-word essays related to leadership and were assessed using the frameworks for higher education qualifications of UK degree-awarding bodies (Quality Assurance Agency, 2024) at level 5 and a personal development plan at level 6. These were established modules and the Blackboard sites also had short online courses provided to help students understand how to access and use the feedback received from previous module assessments.
There were eight lecturers in total, four on each team. Two lecturers (one on each team) had previous experience of verbal feedback. The remaining six had no previous experience of verbal feedback. Two lecturers on each team had some previous marking experience with one on each team being new to all marking. A marking guide was provided to ensure consistency and equity in award of marks and to support the new markers on both teams; internal moderation was undertaken prior to the release of the feedback.
The voice comment feature on Blackboard at the top of the feedback summary was used for audio feedback, with a maximum of 3 minutes of speech available. The markers used their voice tone and inflection to provide warmth and interest in all aspects of the essay (Thomas et al, 2017). Prior to commencing marking, the markers met to discuss how their voice may be used to convey non-verbal feedback that motivates, provides authenticity and supports understanding of the message (Killingback et al, 2019). Markers provided individual written feedback followed by a verbal report for the overall feed forward summary. The audio feedback related to both positive and negative aspects of the essay, including content and academic writing style and three feedforward points were included for future submissions.
A template was used for consistency of marking and descriptors attributable to the marking criteria were used accordingly (Box 1). Markers made a record of the time spent providing feedback for each learner so that comparison could be made on efficiency of verbal feedback. Assignment submissions were anonymised.
Recorded script
Hello there. I am pleased to say that you have met the aims of the assessment and passed! Well done!
Now listen to the feedback that we have provided and go over your essay carefully, using quick marks to identify where you can develop your work in future. We have provided you with examples and advice here that will help if you follow this.
You selected a useful example of leadership in practice to review and you have demonstrated (descriptor) knowledge and understanding of most issues and concepts in relation to several leadership styles that you have witnessed in practice.
You have also demonstrated (descriptor) critical evaluation of how different leadership styles are adapted within the health care setting. You have reflected on the leadership style that you have witnessed and the rationale for the use of each style is also (descriptor).
There is (descriptor) evidence of structure and planning here too.
You have presented (descriptor) arguments here and demonstrated (descriptor) evidence of reading. You have used your reading (descriptor) to support your arguments.
Your reading is (descriptor).
Your referencing is (descriptor).
Going forward, here are three pointers that will help you to improve your future work (list three points).
Overall, this is a (descriptor) submission. This essay and the work preparing for it will help you to develop your own leadership style in practice in the future.
I have enjoyed reading this reflection.
Well done again!
Data collection
This innovation was evaluated using an anonymous online evaluation questionnaire via the QualtricsXM platform. The questionnaire was created by the authors based on the literature, and was also used in the pilot study. It was not validated. Open-ended questions were used to ask learners which method of feedback they preferred and why.
The anonymous online evaluation was emailed to both cohorts (n=129) after release of their marks in June 2022. A reminder email was sent after 2 weeks. The evaluation asked respondents to select between written feedback, verbal feedback, both equally or neither for five questions on which type:
Participants were also asked how satisfied they were with the feedback they received in their preferred format (very satisfied, satisfied, neutral, unsatisfied, very unsatisfied). After each question, respondents were invited to explain their answer in free text.
Markers were also asked to complete a simple evaluation questionnaire. This followed the same format as that completed by the learners, with questions amended to elicit information in relation to the marking processes.
Data analysis
The responses were collated descriptively on the Qualtrics platform. Responses to open questions were typed and collated into broad themes using thematic analysis principles (Braun and Clarke, 2021).
Ethical considerations
Ethical approval was not required, as this was an education evaluation. Information was provided in an email and at the beginning of the evaluation questionnaire, so that students could decide to take part or not. The questionnaire was anonymous.
Results
In total, 31 responses were received, representing a 24% response rate. Half (54.8%) of the respondents preferred verbal feedback to the traditional written method. Three themes emerged from the comments: personal connection and motivation, communication clarity and detail, and retention and accessibility.
Personal connection and motivation
Verbal feedback cultivated a stronger personal bond and boosted motivation by facilitating direct engagement and emotional involvement. The recordings were easier and quicker to listen to and they appreciated the personal approach. Some felt that written feedback often felt ‘copied and pasted.’ Learners appreciated feeling more supported by their assessor, which they found motivating and reassuring.
‘I liked hearing a voice, it felt more personable. It helped me to link into the essay more. I liked the fact that I was able to understand my good points and bad points more clearly’.
Communication clarity and detail
Written feedback offered comprehensive understanding through its detailed and clear information, but learners felt that verbal feedback gave clarification on points that they did not understand.
‘Text can be misinterpreted, and I found some feedback in the past could be taken negatively or in the wrong way. The verbal feedback I found was more useful and felt more personalised than notes’.
Students felt that the tone and nuance in the feedback conveyed encouragement and emphasis more effectively than written words, helping them to grasp the significance of the feedback.
Retention and accessibility
Written feedback was easily retained and accessible for future reference, enabling learners to revisit and reflect. However, the direct and personal delivery of verbal feedback boosted retention and understanding.
‘Verbal feedback was a lot more understandable, it felt more personal from the marker to me. It made it easier for me to understand where I require improvement’.
‘I liked that I could have a more personal response from the lecturer, but it made it harder to go back and go over what she said because you had to just listen to the whole audio again. With reading you can obviously re-read over and over different sections. But it was fine, it didn't massively affect me’.
All learners found the feedback easy to access and found written in-text ‘quick marks’ helpful for improving future academic work.
Just under half (45.1%) of learners preferred traditional written feedback. They felt it was easier to read feedforward comments than listen to a 3-minute recording. This was particularly important for those who did not achieve a pass grade, who needed to listen to the feedback several times to elicit pertinent information.
‘I struggled to process what was being said. I prefer written feedback as I can read over it’.
‘It was really difficult to keep track of the three improvement points for future work. Also, to refer back we would have to listen to the whole audio each time. It is much better to have this written to quickly and easily refer to’.
‘I like to have it written to easily flick back and read my areas of improvement without having to listen to a 3-minute video’.
Marker preferences
Markers were divided in their opinion of verbal feedback. Experience of marking appeared to influence this, with more experienced markers preferring verbal feedback, as they found it quicker. Four of the more experienced markers found it easier and stated that the change from traditional feedback was refreshing and broke the monotony of traditional marking. The experienced markers felt that they would like to use this method again.
‘I definitely prefer verbal feedback; it feels much quicker and more efficient. Its been a refreshing change. I really appreciate this approach and would like to use it again’.
For four of the less experienced markers, this process took longer. They also experienced more issues with the technology and had to re-record feedback if the original failed, which was more time consuming. One marker felt that they needed longer than 3 minutes to provide feedback for learners who did not achieve a pass grade.
‘I found the time limit too restrictive, especially for students who didn't pass. It wasn't enough time to fully explain what they needed to improve on. This method just didn't work for me’.
As a result, the four less experienced markers reported that they would not choose to use this method again. However, all markers acknowledged that the feedback templates were useful in terms of providing equitable feedback for learners.
Discussion
Despite the limited feedback received, verbal feedback has become an integral part of the midwifery programme and serves as the main feedback method for several modules at the authors' university. Based on feedback from learner evaluations, learners who do not attain a passing grade (40%) now also receive a written summary of feedback to assist them with resubmissions.
It is acknowledged that some learners can more carefully process and internalise written feedback, whereas verbal feedback may be quickly forgotten or overlooked. Written feedback is permanent and can be referred back to. Having written comments also allows learners to review the feedback multiple times. Carey et al (2017) found that most students considered that verbal feedback was as important as written feedback in a large survey evaluation of feedback with all undergraduate students at a UK university. Digital audio also enables learners to listen repeatedly to feedback and has been noted to enable improved clarification of key points (Paterson et al, 2020; Race, 2020). This provides an inclusive element for those who prefer audible formats (Matheson et al, 2018).
Paterson et al (2020) completed a systematic review of student needs and preferences for academic feedback and suggested that multimodal styles of feedback (written and verbal) may be more acceptable. Student's value personalised, individual, empowering and timely feedback that is manageable and easy to deal with for future assessments (Race, 2020). Feedback provided in audio files can be explained succinctly and more easily than in writing (Race, 2020), and the use of voice has demonstrated that students may feel that they are acknowledged and recognised as an individual (Killingback et al, 2019). Furthermore, Killingback et al (2019) noted that it is easier to praise students using verbal techniques, which promotes confidence and motivation in the learner.
As cohort sizes continue to increase (NHS England, 2023b), it is important that lecturers explore more efficient ways of working to be able to manage their own workloads (RCM, 2023b). It is noteworthy that the experienced lecturers in this project found the verbal process quicker.
Currently, verbal feedback is restricted to a general summary for midwifery learners at the authors' institution, facilitated by the use of a marking template for simplicity. In the future, there may be potential to expand this to include all feedback, including personalised in-text comments. This style of feedback should be explored further, as the personalised element was favoured by several learners in this project. Other digital methods, such as video recorded feedback, should also be explored (Race, 2020).
Digital learning
The integration of digital health technologies has revolutionised various sectors of healthcare, and midwifery is no exception. For midwifery learners, understanding and using digital health tools and technologies has become increasingly essential in providing efficient, accurate and patient-centred care (Peacock et al, 2022).
Digital health provides opportunity for midwives to provide better quality, safer and a more efficient service (Jimenez et al, 2020). For services to take full advantage of these systems, it is important that the workforce is digitally literate and conversant with the technologies available to them. Introducing digital learning to learner midwives helps them to develop skills in digital health that they will require as practitioners in an advancing modern world.
Digital health technologies offer a plethora of benefits in midwifery care, enhancing both the quality and accessibility of services provided to women and birthing people (Mathews et al, 2019). One of the significant advantages is the ability to provide personalised and patient-centred care through digital platforms. Mobile applications and online portals offer women access to comprehensive information, resources and support throughout their pregnancy journey. These platforms empower women to take an active role in their care, promoting informed decision making and self-management of their health (Ngo et al, 2020).
Benefits in assessment feedback
Digital health technologies offer advantages in delivering feedback to midwifery learners, transforming the traditional feedback process into a more interactive, personalised and effective experience. One benefit is the use of digital platforms and online portals to provide real-time feedback to learners. Interactive digital platforms allow educators to provide timely and constructive feedback on student assignments, clinical performance and competency assessments, facilitating immediate reflection and learning (Pinto and Leite, 2020).
Another benefit is the use of voice to demonstrate praise, boost confidence and address individual needs in a compassionate format (Kiliingback et al, 2019). This provides the opportunity to mitigate emotional distress when feedback illustrates that the learner has not gained as high a mark as expected (Paterson et al, 2020). Experiencing feedback in this format will also provide experiential learning, which may be translated into future practice using digital technologies for communication in maternity care (Healthcare Communications, 2021).
Challenges in assessment feedback
There is potential for digital technologies to depersonalise the feedback process and reduce the quality and depth of feedback provided to learners (Carless, 2022). While digital platforms offer opportunities for real-time and multimedia feedback delivery, it is essential to ensure that the feedback remains personalised, constructive and tailored to individual learner needs and learning styles. Educators must receive adequate training and support to effectively use digital health technologies and maintain the human touch in their feedback approach, fostering a supportive and collaborative learning environment. The authors' experience indicates that generating verbal feedback was time consuming for less experienced lecturers and support is needed for those who are new to this element of the midwifery profession.
The accessibility and digital literacy skills of learners must be considered to ensure equitable access to digital feedback resources and tools. Some learners may face barriers because of limited access to technology, internet connectivity or access issues, or a lack of familiarity with digital platforms and tools (Healthcare Communications, 2021). Educational institutions should provide support and resources to enhance learners' digital literacy skills and address disparities in access to technology, ensuring that all learners can effectively use digital health technologies to engage with and benefit from feedback (Saykili, 2019).
Implications for practice
Finding new ways to develop student confidence and competence in digital literacy is a challenge for nursing and midwifery educators (Terry et al, 2019). Evidence suggests that learners find lack of preparation and access to digital healthcare systems frustrating (Regmi and Jones, 2020). Higher education institutions have a distinct opportunity to collaborate with healthcare providers to enhance the training of healthcare professionals, including midwives, in using digital healthcare systems (Peacock et al, 2022).
Limitations
The response rate was low, possibly because of the timing of the project. At the time of the study, students were preparing to qualify as midwives or moving into their final year, so this project may not have been a priority.
Conclusions
Digital health technologies offer transformative opportunities to enhance assessment feedback for midwifery learners, making the process more interactive, personalised and effective. While challenges such as depersonalisation of feedback and disparities in digital access and literacy persist, proactive measures, ongoing training and continued innovation can help overcome these challenges and unlock the full potential of digital health technologies in assessment feedback. As midwifery continues to embrace the digital revolution in education, educators and educational institutions must collaborate to harness the power of technology and drive positive learning outcomes for midwifery learners and future health care professionals. This will enable learners to feel more comfortable in this emerging world. Embracing and leveraging the benefits of digital health is essential for preparing midwifery learners to become competent, confident and compassionate midwives capable of delivering high-quality care in today's digital age.