Int. J. Nurs. Educ. Scholarsh. 2016; 13(1): 1–11

Margaret Ann Quance*

Nursing Students’ Perceptions of Anecdotal
Notes as Formative Feedback
DOI 10.1515/ijnes-2015-0053
Received August 3, 2016; revised June 15, 2016;
accepted June 20, 2016

Abstract: Anecdotal notes are a method of providing
formative feedback to nursing students following clinical
experiences. The extant literature on anecdotal notes is
written only from the educator perspective, focusing on
rationale for and methods of production, rather than on
evaluation of effectiveness. A retrospective descriptive
study was carried out with a cohort of 283 third year
baccalaureate nursing students to explore their perceptions of anecdotal notes as effective formative feedback.
The majority of students valued verbal as well as anecdotal note feedback. They preferred to receive feedback
before the next learning experience. Students found the
quality of feedback varied by instructor. The anecdotal
note process was found to meet identified formative feedback requirements as well as the nursing program’s
requirement for transparency of evaluation and due process. It is necessary to provide professional development
to clinical nurse educators to assist them develop high
quality formative feedback using anecdotal notes.
Keywords: clinical evaluation, formative feedback,
anecdotal notes, nursing students, verbal feedback

Feedback is commonly considered an essential element of
the learning process (Hattie & Timperley, 2007; Juwah
et al., 2004; Nicol & Macfarlane-Dick, 2007). Feedback
has been conceptualized by Hattie and Timperley “…as
information provided by an agent regarding aspects of
one’s performance or understanding” (p. 81) and is necessary to the development of self-regulated learning strategies (Clark, 2012; Hattie & Timperley, 2007). “Good”
feedback practices include: teacher and peer dialogue,
statement and clarification of expected/desired goals
and standards of performance, opportunities for students
to improve their performance, quality information

*Corresponding author: Margaret Ann Quance, School of Nursing
and Midwifery, Mount Royal University, 4825 Mount Royal Gate SW,
Calgary, Alberta T3E 6K6, Canada, E-mail: mquance@mtroyal.ca
http://orcid.org/0000-0001-7460-2512

provided to students about their learning, and encouraging positive motivation and self-esteem of students
(Juwah et al., 2004; Nicol & Macfarlane-Dick, 2007) and
must be related to the particular learning context
(Hattie & Timperley, 2007, p. 82). Formative feedback
must involve students in strategies such as personal goal
setting, monitoring and reflection, thus promoting the
development of self-regulated learners (Clark, 2012).
Formative feedback “has been shown to improve students’ learning and enhance teachers’ teaching to the
extent that learners are receptive and the feedback is on
target (valid), objective, focused, and clear” (Shute, 2008,
p. 182). It is also clear that “assessment drives learning”
(Van Der Vleuten et al., 2012, p. 207) and multiple assessment points for learning are ideal (Van Der Vleuten et al.,
2012). Narrative feedback helps students to identify
strengths and weaknesses in their performance and can
be effective in developing strategies to improve performance (Govaerts, Van de Wiel, Schuwirth, Van der
Vleuten, & Muijtjens, 2013).
Theoretical courses provide opportunities for formative feedback in part through imbedded assessment strategies. Appropriate feedback allows students to see how
well they are doing/learning. This feedback will allow/
encourage students to undertake self-remediation activities or seek help from professors to improve their learning and performance. Provision of opportunities for
formative feedback are considered so important that academic regulations in many Canadian university settings
specify how much feedback students should receive (in
the marking of assignments, tests and papers) before a
final exam. What is not clear or well understood is how
formative feedback is provided to students who learn and
practice in experiential or practice settings. At a nursing
education conference in Western Canada where the
results of this study were disseminated, session participants indicated that verbal feedback to students was the
format most used in practice settings. Participants stated
documentation of feedback usually occurred only when
the student performed in an unsafe manner and/or was
in danger of failing. This practice is consistent with
research findings (Duffy, 2003; McCarthy & Murphy,
2008) perhaps indicating “educators were only concerned
with safe practice and not with the knowledge and

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M. A. Quance et al.: Nursing Students’ Perceptions of Anecdotal Notes

behaviours and attitudes necessary to support it”
(Deegan, Burton, & Rebeiro, 2012, p. 46). The practice of
initiating documentation only when the student is not
performing well and therefore not meeting course objectives also violates identified principles of good feedback
practices (Juwah et al., 2004; Nicol & Macfarlane-Dick,
2007) and may indicate a lack of standards or guidelines
for evaluation in the clinical setting (Orchard, 1994).

Literature review
Nursing education textbooks recommend anecdotal
notes (AN) as one way of providing written feedback to
students about their clinical learning experiences
(Billings & Halstead, 2012; DeYoung, 2009; Emerson,
2007; O’Connor, 2006). The majority of the literature on
AN has been written from the perspective of the educator, detailing the purposes and process of AN. One academic calendar statement recommends that instructors
“keep anecdotal notes on all students and encourage
students to keep their own notes about clinical situations” (University of Saskatchewan College of Nursing,
2014). However, schools of nursing generally have not
published or made readily available the evaluative process used for experiential courses.
AN are described as individualized objective written
narrative accounts or observations of each student’s
behaviour and/or interactions in clinical settings
(Bonnel, 2009; Hall, 2013; Hall, Daly, & Madigan, 2010;
Liberto, Roncher, & Shellenbarger, 1999). They are one
way to provide formative feedback to the student with
the intent of supporting student learning in order to meet
the intended goals and outcomes of a clinical course.
As Smith, McKay and Richardson (2001) comment:
Feedback provides students with the information needed to
overcome weaknesses, improve overall performance, and gain
confidence in their clinical competencies. This feedback
should identify the adherence to and deviation from established policies, standards, and procedures. Clinical instructors
should document the feedback provided, along with suggestions and recommendations for improvement where applicable, and a specific time frame for behavioural change.
(“Principle 4,” para.1)

The available literature does not specify how AN are
created. The development of process and policy related to
AN as a method of formative feedback appears to have
been left to each school of nursing to develop for itself
and is not reported in the literature. Hall et al. (2010)
identified a lack of published literature on the use and

value of AN. In the past ten years, there is a noted lack of
research and writing pertaining to about AN. No research
has been found that focuses on students’ perceptions of
the value of AN. This creates a concern for those education programs using AN for experiential learning. If students do not find AN an effective way of providing
necessary and helpful feedback, then educators need to
find another and/or different way of providing feedback
that is useful to students for their learning.
There is an established link between the need for
documentation (which can be AN) and student progression in nursing courses and/or program (Emerson, 2007;
Larocque & Luhanga, 2013; O’Connor, 2006; Smith et al.,
2001). Smith et al. (2001) discuss several legal cases where
the outcomes were supported by well written, factual,
non-judgmental and objective AN describing student clinical performance. There is also a human rights requirement for due process in clinical evaluation of students
with “all relevant procedures…applied fairly, equitably
and with clearly defined rights and duties” (Scanlon,
Care, & Gessler, 2001, p. 24) for faculty and students.
This is not unlike the documentation of nursing care,
with the requirement of similar principles and the possibility of scrutiny by professional and judicial bodies (e. g.
Canadian Nurses Protective Society, 2007; College and
Association of Registered Nurses of Alberta, 2006). Well
written, factual, non-judgmental and objective AN provide
a transparent picture of the evaluative process for the
student as well as for faculty, meeting part of the requirement for due process. Students should come to their midterm (formative) or final (summative) evaluations,
confident in his/her knowledge about the final mark.
Utilizing a documented evaluation process would provide
transparency for the student ensuring there are no unexpected or unwelcome “surprises” (near failures or failures)
that would impact student progression through a nursing
education program (Buck, Wilkinson, & Phillips, 2014).
Two studies were found describing the use of AN in
clinical evaluation of nursing students. Hall et al. (2010)
conducted a descriptive study investigating the use of AN
by clinical faculty. Of 64 responses from six American
schools of nursing, 68.8 % reported weekly use of AN
with another 28.1 % reporting occasional use of AN during the semester. AN were mostly used to describe student practice with regard to medication accuracy,
attention to patient safety and professional behaviours.
The authors comment, “…it is of some concern that accuracy in medication administration was rated highest of all
reasons to use an anecdotal note. Although medication
administration is obviously central to patient safety,
other aspects of care may have even more significant

M. A. Quance et al.: Nursing Students’ Perceptions of Anecdotal Notes

implications for overall patient well-being” (Hall et al.,
p. 158). One weakness of this study concerns the lack of
description of the processes that were used for the AN.
This study presupposes that AN were being used the
same way across all programs. However, this assumption
confounds understanding of the results. We do not know
what the AN processes are for each school and should not
assume they are similar.
Hall (2013) expanded the previous descriptive study,
including Canadian and American schools of nursing.
An electronic survey was sent out to faculty in 10 % of
all Bachelor of Science in Nursing (BSN), Associate of
Science in Nursing (ASN) and Canadian nursing programs,
with 784 responses (23.3 % response rate). Similar to Hall
et al. (2010), 62.4 % of faculty used AN “almost always”
(p. 274) and 28.2 % reported occasional use. Faculty
most often used AN to record student attention to patient
safety issues and least to document incorporation of
discharge planning. Qualitative feedback from faculty
(309 responses) indicated they used AN to provide formative feedback to students (18.7 %), as evidence when
completing final evaluations (12.3 %), self (educator)
organization (12.3 %) and demonstration of student progression in competence in clinical settings (12 %). When
considering the number of responses in the qualitative
feedback, it is concerning how few faculty reported using
AN for formative feedback (18.7 %) or as data for final
evaluations (12.3 %). How are formative and final evaluations being developed? How is transparency of evaluation
and due process demonstrated? The same weakness is
noted in this study as in Hall et al. (2010). No information
is provided about the processes of AN development and
we cannot assume they are similar.

Anecdotal note processes
Over 1,600 students were enrolled in a four-year bachelor
of nursing program at a Canadian school of nursing.
Students begin their clinical practicum in the first year
of their studies. As part of their workload, full time
faculty are expected to have a certain number of hours
of clinical supervision. However, the majority of clinical
supervision was and is done by sessional clinical nurse
educators (CNEs).
In nine of the ten clinical courses in this nursing
program (See Table 1), a CNE will be present on the
clinical unit (acute care or community settings) with a
maximum of eight students. This model of clinical
instruction allows for development of long-term teacher-

3

Table 1: Clinical courses by program year.
Year of
program

Course



Nursing  Professional
Practice I
Nursing  Professional
Practice II
Nursing  Professional
Practice III
Nursing  Adult Health
Nursing  Family
Newborn Health
Nursing  Child Health
Nursing  Mental Health
Nursing  Seniors’ Health
Nursing  Integrated
Professional Practice
Nursing  Transition to
Independent Practice







Clinical
hours

Length of
course



 weeks



 weeks





 weeks or
 weeks
 weeks
 weeks






 weeks
 weeks
 weeks
 weeks



 weeks

student relationships during each clinical course which is
beneficial to student learning (Bok et al., 2016, p. 92). The
final course in the program, Nursing 5114, is the only
clinical course using a preceptor model of instruction.
In the development of the Bachelor of Nursing
curriculum, a detailed method of AN development was
formalized that provides narrative weekly formative feedback from the CNE to each student in the clinical group.
This process provides opportunity for student reflection,
clarification and weekly goal development, and creates
“data” for midterm and final evaluations. Through this
AN process, transparency of evaluation was thought to be
facilitated and due process of evaluation could be seen
by the student.
AN were written on pre-formatted forms customized
for each clinical course (See Table 2) that contain program outcomes and specific course objectives. CNEs write
their narrative observations on the AN document and
send an electronic copy to each clinical student in the
group, usually 2 days after the completion of the clinical
experience. Each student is expected to review and then
respond to the CNE’s comments in the AN. The student
sends the individualized AN back to the clinical nurse
educator for review before the next clinical experience.
The intent is for each student to use his/her individualized AN to reflect on his/her clinical practice, to “see”
if they were meeting course expectations and develop
plans to correct performance issues, with the CNE’s assistance. CNEs are expected to use AN documentation as
“evidence” when developing formative (midterm) and
summative (final) evaluations. The need for “data” for

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M. A. Quance et al.: Nursing Students’ Perceptions of Anecdotal Notes

Table 2: Excerpt of anecdotal notes document for Year 3.
Benchmarks and objectives

Learning Objectives

Instructor Observations
and Feedback

. Practice evidence based, ethical, safe
& effective nursing care, integrating
theoretical and practical knowledge,
with individuals, families, communities
and population (IFCP) groups in
nursing practice & simulated settings.
Objectives:
a) Demonstrate critical thinking,
problem solving, and decision
making skills using relevant
evidence informed knowledge.
b) Demonstrate self-preparation for
clinical practice, while seeking
appropriate instructor guidance
when required.
c) Collaborate with the
interprofessional team.
d) Effectively apply the nursing process
in complex care situations.
e) Demonstrate safe and ethical
nursing care for individuals, families
and communities.

Demonstrate:
– articulation and adherence to the
Canadian Nurses Association Code of
Ethics and College and Association of
Registered Nurses Professional
Practice Standards.
– safe performance of all care measures
and skills with growing accuracy
– adherence to university and agency
policies and procedures.
– preparation for each clinical practice
day including application of relevant
evidence-based literature.

Student Response

Identify in collaboration with the IFCP:
– planning care in response to the
changing health needs of client(s),
giving evidence of knowledge-based
practice.
– reflection and evaluation of care
appropriateness and effectiveness.

Evaluate effectiveness and outcomes of
nursing practice

formative and summative evaluations, and the requirement for transparency of evaluation and due process are
considered important enough that AN use, timely return
to the student and expertise are embedded into the position descriptions and evaluation documents of CNEs.
Clinical course coordinators (full time faculty) regularly
check to ensure CNEs are doing individualized and timely
anecdotal notes. These processes meet the suggested
requirements for formative feedback (Clark, 2012;
Govaerts et al., 2013; Hattie & Timperley, 2007; Van Der
Vleuten et al., 2012).
There is little published literature relating to the
faculty’s use of AN or the value of AN as a formative
feedback process in experiential/clinical evaluation. It is
important to understand the student perspective in order
to determine the value of AN to student self-reflective
learning.
A quality improvement survey was conducted a
year before this study. Third year nursing students were
surveyed about their experiences of AN over the first three
years (seven of ten clinical courses) of their program. Two
hundred and thirty-six students reported on their

experiences with AN. It was found that half the CNEs
were not initiating AN according to the program expectations. Student perceptions included the following findings: 66 % of students found it helpful to reflect on the
CNE’s AN and the majority found it helpful to receive AN
before the next week’s clinical experience. Only 46.6 % of
the students preferred clinical nurse educator initiated AN.
Many students (45.6 %) preferred no AN, but expressed a
preference for only verbal feedback on their clinical performance. It was speculated this finding reflected the
delay in formal student feedback as well as a reflection
on the amount of students’ work required to produce AN.
In contrast, instructor verbal feedback requires no physical student work. A targeted educational program was
implemented for the CNEs to increase the incidence of
CNE-initiated AN. The next step was to conduct a formal
study of the students’ perceptions of the AN process.
This descriptive survey of nursing students’ experience of AN would begin to fill the gap in the nursing
education literature. The research question was: what
were students’ perceptions of AN as a formative feedback
tool?

M. A. Quance et al.: Nursing Students’ Perceptions of Anecdotal Notes

Methods
Data collection methods
This cross sectional exploratory study was a survey of
third year nursing students (N = 283) in 2011 using three
forced choice questions and two open ended qualitative
questions. The quality improvement survey served as
a pilot test for the formal study with study questions
revised to improve student understanding of the
questions.
Ethics approval was received from the educational
institution’s Human Research Ethics Board. All third
year students were invited to attend an orientation to
the nursing course “Adult Health”, the last course in
the third year of their four year nursing program. Once
the orientation was complete, the researchers introduced
the study, using a powerpoint format and answered questions. The survey was handed out to all students at the
same time. Students were asked to complete the survey
and hand it back. They were informed that their names
should not appear on the survey, providing student anonymity. If students did not want to participate, they were
instructed to hand in the blank survey. This study design
used the process of implied consent. The data collection
process took 20 min.
Demographic data was not collected as it was the
intent of this study to gain an overall impression of
students’ perceptions of the value of AN to their learning
and evaluation processes. A more simplistic, exploratory
study design was appropriate.
Question 1 asked how AN had been used in each
clinical course. Specific information was sought as to
whether AN were CNE initiated, student initiated or
there were no AN provided. Question 2 asked each student for his/her preference for AN to be CNE, student
initiated or no AN. Question 3 asked what kind of feedback students found most useful for their clinical learning with forced options given for daily verbal feedback,
weekly anecdotal or feedback through midterm and final
evaluations only. Question 4 asked when it was most
useful for students to receive their AN. Forced options
were: before the next clinical experience, during the next
clinical experience or in the preconference time of the
next clinical experience. Question 5 asked students if CNE
feedback, provided in the AN, assisted them in setting
goals for the next clinical week. There was opportunity
for qualitative responses for Questions 2 and 5. Data were
analyzed through descriptive statistics and thematic analysis of the qualitative feedback.

5

The qualitative comments were analyzed with the
responses were first sorted by responses to: instructor
initiated, student initiated and no AN (Question 2) and
“Yes”, “No” and “Other” (Question 5). Each researcher
read all responses to individually and sorted the
responses by frequency of reoccurring words and phrases.
The researchers then came together and reviewed their
word/phrase sorting together, determining overarching
themes. When there were questions about the meaning
of words and phrases, the literature was consulted
to understand the most recent meaning. This process
continued until consensus was achieved between the
researchers.

Results
There was a response rate of 79.4 % (n = 235) of 283
students registered for Nursing 3104, Adult Health. It is
not known if the 48 non-participating students refused
to participate or were not present for the orientation
session.
The surveyed students had experience with two ways
of receiving AN formative feedback. During the first three
clinical courses in first and second year of the program
(Professional Practice I, II and III), students would write
AN notes and send them to the CNEs for comment. This
was called “student initiated” AN. The School made a
policy change after the third clinical course that required
the CNEs to write AN and send them to the students for
comment. This was called “instructor initiated” AN.
In Question 1, students were asked how AN had been
used in seven clinical courses in first, second and third
year (See Figure 1). Of the potential respondents (n = 235),
the number of “no responses” to this question by course
ranged from a maximum of 4.4 % (Nursing 3134) to a
minimum of 1.3 % (Nursing 3124). This was interpreted
to mean that the majority of students remembered and
could report on how AN were used in a particular course.

Figure 1: Student experience of anecdotal notes by course.

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M. A. Quance et al.: Nursing Students’ Perceptions of Anecdotal Notes

There were a number of students who reported not doing
or receiving any AN, with three courses showing more significant rates. Students reported receiving “no AN” 13 % of
the time in Nursing 3124, 15.5 % of the time in Nursing 2216,
and 18.4 % of the time in Nursing 3134. The remaining clinical courses had “no AN” rates ranging from a .44 % (Nursing
1214) to 7 % (Nursing 3114). These latter course rates were
considered by the researchers to be acceptable, given the
large number of students in the cohort. These differences in
rates between courses presented important questions for
faculty and administrators: how were students who receiving feedback about their clinical performance? How were
CNEs collecting “evidence” in order to do midterm and
final evaluations if they had no “evidence” provided by
AN? These results raised concerns about students’ evaluative
processes and if the principles of transparency and due
process were provided to these students.

200
180
160
140
120
100
80
60
40
20
0

opportunity for students to modify their behaviour to
meet the course expectations as interpreted by the CNE.
Although CNEs are charged with comparing student
behaviour to program and professional standards, it is
not unreasonable to assume that students spend significant time to figure out that particular CNE’s individual
expectations of student behaviour. This is reflected in our
study, evidenced by the following statements:
[AN] helps the student understand the CNE’s perspective,
because they have more knowledge and criteria as to how the
student should perform in clinical.
Every CNE expects something different. If they initiate [the AN], it
is easier to reflect appropriately.

Students found that AN provided a one to one, confidential feedback mechanism with the CNE that not only identified weaknesses in their clinical practice but also areas of
strengths. In fact, students in our population mentioned AN
commented on their strengths many more times than their
weaknesses. Students identified that recognition of their
strengths helped them to develop a sense of confidence.
…. Sometimes I forget examples of awesome things I did.

Clinical Nurse Educator Student Inititated
Inititated

No Anecdotal Notes

Figure 2: Student preferences for anecdotal notes.

Question 2 asked students to indicate their preference for AN
from three options and asked for rationale for their choice
(See Figure 2). Overwhelmingly, students preferred clinical
nurse educator initiated AN (n = 174, 74 %), followed by a
preference for no AN (n = 40, 17 %) and student initiated AN
(n = 16, 6.8 %). A large majority (88.9 %) of the students
provided comments giving rationale for their choice with
over 73 % commenting on instructor initiated AN.
Qualitative student comments included statements such as:
I liked to see what the clinical nurse educator noticed that may
not be as obvious to myself. But I like adding to their comments
on skills that they might have missed.
CNE have the knowledge as to what is important to focus on when
students are preoccupied and everything. It also gives the student
an idea of what the clinical nurse educator knows and thinks
about their (sic) practice. Keeps us updated on our status.

Generally, students saw value in “seeing” their behaviour documented in the AN. This feedback provided

Transparency of performance is one way of ensuring
fairness and equitability of evaluation. Students found
that AN made student performance “transparent” for
both the clinical nurse educator and student. As one
student commented,
[AN] help me to know what they think I need to work on so I’m
not taken by surprise at evals [evaluation time].

Students identified it was helpful to have areas for
improvement identified verbally before the ANs were
received. This meant students were not surprised by the
CNE feedback in the AN, which sometimes was perceived
as a negative experience. For those students (17 %) who
identified a preference for no AN, many chose this preference based on their negative experiences with AN.
Student initiated AN were identified by students as a
significant additional workload for students. Dissatisfied
students who had CNE initiated AN noted:
Some CNE give little feedback.
The anecdotal [notes] seem general and similar every week and
[every clinical] course with no gain to learning.

However, one student simply said, “Because I like verbal
feedback instead”.
Question 3 asked students for their preferences for
feedback related to their clinical learning. Many students

M. A. Quance et al.: Nursing Students’ Perceptions of Anecdotal Notes

7

indicated more than one preference. However, most students (n = 164, 69.8 %) liked daily verbal feedback, followed by weekly AN (n = 78, 33.2 %) and midterm and
final evaluations only (n = 30, 12.8 %). This result clearly
indicates that use of only one form of feedback is not
fulfilling student needs. CNEs require skills in the provision of verbal and written feedback.
Question 4 asked students to indicate their preferences for timing of receiving feedback through AN (see
Figure 3). Most students (n = 188, 80.7 %) chose before the
next clinical experience with no clear preference
expressed for any of the other options.

A number of students (n = 40, 17.1 %) indicated AN did not
help them set goals and, in fact, increased their workload.
This student group had three years of experience of AN
from several different CNEs. Many student qualitative comments were related to the quality of CNE comments and the
accountability of the CNE to do “good” AN. Students stated
that “good” anecdotal notes were detailed and related
directly to the individual student’s experience. They contained exemplars of positive behaviours as well as areas
that required development. One student commented:

200
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60
40
20
0

Students also found inconsistency of AN between
CNEs and were able to identify those CNEs did not like
doing AN and/or did them poorly. The differences in CNEs’
ability to “do” AN produced frustration and confusion.
Often, feedback is vague and appears generalized. The opportunity to respond is restricted and fails to provide an opportunity to learn, or understand the depth.
Before the next clinical
experience

During the next clinical In pre-conference of the
experience
next clinical experience

Figure 3: Student preferences when to receive anecdotal notes.

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80
60
40
20
0

[AN] ensures the instructor is attending to and engaging with
each student in the clinical [area].

Not all CNEs are consistent with anecdotals and it’s very irritating about feedback. Some CNEs are verbal and don’t care for
anecdotal and others are SUPER picky about them.

Students were also able to identify when instructors
were taking shortcuts with AN, using “copy and paste”
from other student’s AN to develop AN that were vague,
not personalized to the student and were similar to everyone else’s AN. As one student commented,
[AN] show if the instructor gets to know you. I’ve seen multiple
notes given to the wrong student.

Yes

No

Sometimes

Figure 4: Usefulness of anecdotal notes to set learning goals.

Question 5 asked students if AN helped them set
goals for subsequent clinical learning experiences (See
Figure 4). There were a number of significant number of
qualitative responses (n = 84, 36 %) with 63 % of the
responding students providing positive narrative examples. Overwhelmingly, students indicated “yes” (n = 171,
73.4 %). Students commented:
It helps you shape your practice and helps you be a better
student as it aids your learning. Plus it is helpful and nice to
hear positive things about your progress.
It identifies my strengths as well as areas of improvement. Once
I know my challenges, I can plan to work on them in the
following clinical [experience].

The remaining students appeared to be ambivalent in
their responses (n = 7, 3 %). For example, one student
commented:
Yes and no. It depends if you are doing well or not.

One unexpected finding gleaned from the student
qualitative feedback was the students’ the need to give
voice to their perceptions of clinical experiences. Students
used AN to tell the CNE of their experiences, good or bad.
The instructor is not always with their (sic) students when we
perform skills so he/she may not know of all the events that
happened through clinical.
Often the instructor does not see or know what I do each day
and her anecdotal notes do not reflect my full practice.

It appears that some students used AN notes for selfreflection although AN notes were not intended to be a

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M. A. Quance et al.: Nursing Students’ Perceptions of Anecdotal Notes

formal method of self-reflection. AN allowed students to
“tell their story” about something that happened in the
clinical setting of which the CNE may not have been not
aware.

Discussion
The number of students who did not receive clinical
nurse educator initiated AN was of interest. It is unknown
how these students were receiving formative feedback on
clinical performance though it is speculated that verbal
feedback was provided. It is not known how “data” was
gathered for the creation of midterm and final evaluations. Considering the number of students who found AN
useful in planning their personal clinical goals (n = 171,
73.4 %), the lack of CNE initiated AN was concerning.
Following CNE professional development activities for
AN (after the qualitative improvement study the previous
year), the number of CNE initiated AN increased by 50 %.
This suggests that clinical faculty may benefit from periodic professional development related to provision of
student feedback in clinical courses. However, there continued to be specific clinical courses where students were
reported they were initiating AN (contrary to school policy) or they were not receiving any AN (See Figure 1:
Nursing 2216, 3124 and 3134). Other strategies have been
implemented to ensure CNEs comply with program
expectations for AN. Specific information regarding the
construction of AN notes is now included in the formal
orientation for new CNEs. It is also an expectation for
clinical courses to have the weekly AN posted through
the clinical course Blackboard site, allowing AN to be
monitored by the clinical course coordinator (a full time
faculty member) for quality and compliance with the
process. CNEs continue to be evaluated on a regular
basis with demonstrated competence with AN as part of
the required CNE competencies. These strategies are
recommended for a programmatic assessment strategy
(Van Der Vleuten et al., 2012), which AN are intended to
be in this nursing program.
This study indicates that using a very structured
process for AN production and dissemination to students
provided students with “good” (valuable) formative feedback. Students identified AN provided an opportunity for
teacher and student dialogue, statement and clarification
of expected/desired goals and standards of performance,
opportunities to improve their performance from week to
week, and quality information is usually provided to
students about their learning (Juwah et al., 2004; Nicol

& Macfarlane-Dick, 2007). Students also identified this
kind of formative feedback encouraged positive motivation and their self-esteem as well as development of
personal goal setting and reflection (Clark, 2012). An
unexpected finding was many students found AN gave
them a formal place for their voices. Students used AN
notes to describe the experiences that CNE could not or
did not see.
Students identified AN provided feedback about their
clinical performance that translated into transparency in
the evaluation of their performance. It is likely that the
concept of “due process” concerns faculty and administrators more than students, until a student is failing. When
a student is struggling or failing, AN can serve students,
faculty and administrators well by determining if students
received documented feedback about clinical performance, what was needed to improve, and if improvement
was demonstrated. AN can provide a process document
(in our program, on a weekly basis) that then can be used
to support or deny an appeal for a clinical failure. This
facilitates the provision of due process procedures for
faculty and students (Scanlon et al., 2001).
Students in this study preferred daily verbal feedback (n = 164, 69.8 %), followed by weekly AN (n = 78,
33.2 %). This preference indicates that CNEs require
skills in provision of verbal feedback and written feedback. However, verbal feedback requires significant skill
and practice. Educator experience affects the kind of
student feedback provided (Govaerts et al., 2013; Van
Der Vleuten et al., 2012; Wenrich, Jackson, Maestas,
Wolfhagen, & Scherpbier, 2015). Educators with less
experience may act as cheerleaders focusing on positive
rather than negative feedback, take a passive teacher
role, have much concern about students’ fragility, want
to create a “safe” environment to deter student discomfort, have limited goals and strategies, are oriented
toward students’ current (rather than future) needs and
use a private, one-to-one feedback time. More experienced educators are coaches rather than cheerleaders,
act in a dynamic and selectively active role by determining which feedback should be given immediately and
which can be delayed, understand that students are
resilient, create a challenging but safe environment,
are strategic and goal oriented, know what skills the
students should have at different stages of their program/development, and foster an environment of
“team” feedback, using patients and peers to do so
(Wenrich et al., 2015, p. S93). Another study used an
extensive literature review and Delphi process to
develop a description of twenty-five high quality verbal
feedback behaviours of educators (Johnson et al., 2016).

M. A. Quance et al.: Nursing Students’ Perceptions of Anecdotal Notes

Some exemplars of these behaviours include: educator’s
comments were based on observed performance, were
discussed as soon as was practicable, comments are
intended to help, not criticize, the learner needs to be
engaged in the discussion and identify similarities
between the learner’s performance and the target performance, and educator’s comments are focused on the
learner’s actions, not personal characteristics. Zsohar
and Smith (2009) state, “…how the feedback is delivered
to learners is just as important as what feedback is
delivered” (p. 242). Although verbal feedback allows
for immediate formative feedback and building of confidence, (which are student interests), the disadvantage
of verbal feedback is that it cannot be “replayed” or
replicated. When final grade appeals or allegations of
unfair assessments are received, the reliance on only
verbal feedback quickly can move to a “he/she said,
he/she said” scenario which is difficult to adjudicate.
A written feedback process allows for delayed reinforcement of verbal formative feedback, and permits students
to review and refer to the clinical performance data
more than once. There is then evidence of transparent
evaluation processes and therefore due process, which
are interests of the faculty and administrators.

Strengths and limitations
Strengths of the study are in the number of students who
were surveyed and the response rate. These numbers give
some assurance that the results of the survey accurately
reflect the experiences of this cohort. Another strength of
the study is evident in the number of qualitative
responses, both positive and negative, indicating the student engagement with the survey tool and the desire to
have their voices heard. The survey tool and method were
pre-tested in the quality improvement study.
One limitation to this study is the number of students
(48) who did not participate. Attendance was not taken at
the course orientation. It is not known how many students chose not to participate in the study or who were
not present to participate. During the data analysis, it
became evident that the survey tool requires revision.
Question 3, asking “What type of feedback if most useful
to your clinical learning” was confusing to students.
Many students identified many more than three feedback
opportunities. A Likert-type scale and/or some other tool
that allows multiple choices would have been more valuable and would have increased the knowledge of students’ experiences of formative feedback beyond written

9

and verbal methods and formative and summative evaluations. Another limitation of this study might be the
ability of the students to accurately recall their experiences of instructor feedback over a 3-year period.
However, given the numbers of students who were able
to remember their experience of AN in the previous seven
clinical courses of (non-responders varied by course, ranging from 1.3 to 4.4 %) as well as the amount of qualitative feedback, this is not likely a concern.

Conclusion
It is curious that more formal strategies of providing
formative feedback have not been taken up with other
nursing programs, given its identified benefits for students, faculties and programs. One reason might be
because this process of AN development by CNEs is
time consuming. The time it takes to complete AN on
each student in a clinical group was identified by conference attendees at a nursing education conference in
Western Canada as the major barrier for implementing
such a strategy. The availability of qualified clinical nurse
educators is always a concern for nursing education programs, particularly when there is more than one program
in the same area. Creating time consuming means of
documenting student performance may disadvantage a
nursing program’s ability to hire sufficient clinical educators. Not all education programs, particularly in international settings, will have the ability to hire qualified
clinical educators for small groups of students. These
programs will likely need to rely on the preceptor model
of clinical instruction for larger numbers of students.
Preceptors will not have the time to provide more than
cursory verbal feedback and could not be expected to
create written feedback documents for several students
whose care he/she has likely not observed. Perhaps other
strategies should be developed that would somehow capture the intent of written formative feedback, but without
the time consuming narrative component. This study
makes it clear that formative written and verbal feedback
provides benefits to students. Effort should be invested in
creating another method that would shorten the time
involved in the creation of such documentation, yet
meet the principles of formative feedback.
This study was conducted with one cohort of students who shared a similar experience of feedback
about their clinical performance using AN developed
specifically for this nursing program. It is time for this
study to be replicated in this program. There has been

10

M. A. Quance et al.: Nursing Students’ Perceptions of Anecdotal Notes

significant turnover of faculty, both full time and in the
CNE cohort. Additional research should also be conducted with regard to verbal feedback mechanisms,
given students’ perceptions of its value. For example,
what are the faculty, students’ and administrator’s perceptions of verbal feedback? How are clinical failures
appeal processes in other programs managed when verbal feedback is the primary means of providing formative
and evaluative feedback?
The results of the study are a beginning exploration
of the student experience of formative feedback in experiential/clinical settings using a written form, that of AN.
Students identified that verbal and written formative
feedback from the clinical nurse educator provided valuable and required information that students used to build
their confidence in their nursing activities and correct
their performance. The written feedback also allowed
students to give voice to their clinical experience, and
demonstrate their competence for knowledge and skills
that the CNE was unable to witness for him/herself. This
becomes a blending of feedback with reflection on student practice from the perspective of the CNE and students, meeting the needs of students as well as the
nursing program. Students found that “good” anecdotal
notes provided before the next clinical experience were of
value to their learning. Timely verbal feedback while in
the clinical setting was also valued.
Students felt that this nursing program’s way of using
AN provides transparency of their performance and
assisted students with ideas for ongoing modification of
their behaviour prior to the next scheduled clinical
experience. However, students also felt that verbal feedback should be provided first and with that feedback
reinforced in AN format. These strategies met several
pedagogical principles, particularly related to the need
for formative feedback.
Acknowledgements: Dr. Maureen Mitchell, EdD RN, for
her contributions to and support of this project.

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