J van de Ridder et al. (2008) highlighted one of the main faults with regards to feedback, by entailing that there is no specific operational definition of the word (1). This leads to a potential discrepancy between reviews (1, 2, 3). Furthermore, the majority of the current literature is focused on how to appropriately give feedback. It is criticised as “too teacher centred (4) ”, and educator driven (5, 6, 7), rather than showing how medical students can actively receive, respond to, and utilise feedback (8, 9). Not much focus was directed to fostering students’ active participation in obtaining feedback (4, 10). Despite this, however, it has been highlighted that a student’s “proactive recipience” (11) is as, if not more (12), important than a teacher’s role in providing feedback (11). The way a student incorporates, or chooses not to incorporate Feedback, is undoubtedly a key determinant of its efficacy. Therefore, it is important to understand these processes in order to attempt leveraging effective and influential feedback (12). Additionally, because feedback is interpreted via the lens of one’s own perception (12), naturally this would be a predominant determining factor. Motivations (13), fears (12, 13, 14), and expectations (13), all act as key contributors to a student’s perception and in turn have an influential effect on any feedback they may receive (13).
Factors influencing receptiveness to feedback
It is critically important to note that feedback is never provided in a vacuum (12). Despite this, there is still a particular insufficiency of data about different factors that impact the provision and reception of feedback (15). Minor factors such as the alleviation of the threat of judgement, by directing feedback to an individual (16, 17) and not presenting it as a group, is preferred. This has been shown to result in higher grades (16), suggesting heightened receptiveness. Other obvious factors that influence a student’s’ interaction with feedback include their perception to the degree of veracity and specify of said feedback (12). Further research has shown that in order to deliver effective feedback, and have it incorporated, one must consider the student’s goals and therefore, one is unable to “take the ‘self’ out of assessment. (13)
Recognise that feedback is occurring and understanding feedback
Feedback provision is the most frequently criticised aspects, by students, in all of higher education (18). Faculty also suggest it as an area for improvement (4). Currently, this can be primarily attributed to poor provision in a clinical setting (19). There appears to be a stark disparity between teachers’ and students’ opinions on the topic (4, 20, 21). The former feel like they give adequate if not plentiful feedback (21), whereas the latter feel persistently dissatisfied with it (22): wanting more direct observation and feedback (4, 12, 19, 23). Students satisfaction has been shown to arise primarily from praise and compliments (22) and not specific and accurate constructive feedback (4). However, it is with the latter that students learning is facilitated (4, 12, 22, 24). Feedback acts as a fundamental catalyst (22, 25), especially in medical training (26). This may, however, at times be ineffective (12). Thus student satisfaction is not an adequate determinant of quality of feedback (22). This desire for praise and positive feedback (to which the current practice is already currently skewed), is worsening what with the snowflake/ millennial generation’s entry to medical school (4). Indeed, some of this desire is directed at actively seeking constructive feedback, which is often misconstrued as a request reassurance (12).
Another theory explaining the above effect is that students actually don’t realise that feedback is occurring (27). This may be because feedback is both explicit and implicit (21). In the most basic sense, for students to be able to actively engage, they must first of all be able to recognise that feedback is occurring. Feedback is designed to initially make the learner aware of the deficit (27). Its aim is to impart clear understanding by emphasising the discrepancy between intention and outcome (28). It is only after this that suggestions to correct the incongruity should be made (27). By being unable to recognise that feedback is occurring, this process has undoubtedly failed. Naturally, this isn’t the only factor influencing feedback receptiveness, because global awareness of internet accessible feedback still isn’t enough to ensure universal engagement (28). Learners also identify a lack of feedback even when directly apprised that it is transpiring. (4)
Learners may also not recognise feedback is occurring because of lack of comprehension. Students must understand to be able to address the input (18). Further limitations occur when students are not cognisant of criteria against which they’re assessed (18), hindering them in fully understanding the weight of feedback. Undoubtedly, the degree to which feedback has a positive impact on performance is dependent on the learner receiving specific actionable feedback, understanding and accepting feedback and being motivated to change and take action (29). All of these must start with simple recognition. Active engagement may also be inhibited as certain feedback provision is at a low cognitive level, voiding the necessity for interaction and stimulation. (4)
Quantity and quality
Moreover, from quality assurance surveys it was shown that at low volumes quantity of feedback and student satisfaction showed a proportional relationship (30). This increasing satisfaction influenced student receptiveness, but above a certain quantity students begin to feel overwhelmed (30), which may lead to “behavioural disengagement” (31). Excess feedback also decreased the degree to which students had to struggle to entertain difficult concepts, resulting in decreased long term proficiency (12). Further investigation elucidated that quality is a better determinant for receptiveness (30). The overall quality of feedback is recognised as being dependent on tutor profile (5, 32). This, however, is not in relation to intelligence or specialty, as trainees appear to be the most consistent provider of FB (19). Generalists have been shown to provide more learner centred feedback, with elaboration on communication and professionalism. Specialty block featured highly in the literature (19, 32), with demands from learners for more training in how to provide feedback (19). Feedback was associated with high quality teaching (21, 22) and also high quality learning (33). Despite this quality however, its correlation with assimilation is not always positive (34). A similar lack of association was noted between engagement and success (34). This is potentially because students infer from their own background that feedback does not valuably contribute to higher evaluation (35). Students with greater levels of positive experience, and therefore confidence (12), may also show greater levels of discounting feedback by drawing from own personal encounters that this skill has already been “achieved (12). This has been shown to potentiate future discounting of successive feedback (31).
Timing and immediacy
A further factor which potentially influences students’ receptiveness to feedback is its immediacy, whose employment, much like general feedback itself, is variable (17). Nevertheless, despite the limits in opportunity, rapid feedback is still viewed as highly valuable (36). Acting paradoxically, immediacy of feedback can serve to help or hinder development by supporting metacognitive gains or potentially limiting the capacity of reflection, respectively. (37) Other as
pects of feedback timi
ng (7), especially at the end of the module, highlights important information, causing reflections by prioritising multiple observations (29). The necessity for autonomy with regard to self determination theory (SDT), is usually not satisfied through feedback. This is especially the case if an educator enacts why, when and how feedback is provided. (21). Naturally, the resulting decrease in intrinsic motivation may serve to similarly affect receptiveness to the overall process. Current
educational alliance models show three facets of learner behaviour (9), and those who actively seek feedback will, according to SDT, benefit most from the efficacy of feedback (21).
Maturational aspects and learner stage
Maturational aspects were also highlighted and served to portray different perceptions of feedback, varying with age (8, 38), and self esteem (4). Junior students (38) as well as learners with low self esteem (4) are more passive and tended to show less initiative to seek feedback. They also preferred feedback that was positive (8 38), confirmed their progress and provided reassurance (38). More senior students and students with stronger egos, however, preferred feedback that informed them of their specific learning needs and personal development (38). Senior students were also less dependent on the confidence boost, favouring negative feedback. Both groups valued immediate informal feedback from anyone – peers, more senior students, and staff. (38) Therefore, it can be seen that you can increase engagement and receptiveness, to feedback, through tailoring messages (11, 12, 18) to an individual. However, to enhance the benefit gained one must be trained to engage with different types of feedback messages (11). Productive feedback should be in tune with learner stage and desired educational result (38), which also particularly enhances receptiveness. It is this explicit calibration of educational goals between student and teacher which appears to be crucial in nurturing a beneficial “educational alliance” (38).
Misalignment of values and bias
There also appears to be moderate misalignment in the perceptions between students and doctors, particularly with regards to the context dependent weighting of feedback terms. This potentially leads to students discounting negative feedback on certain key skills, but valuing if positive feedback is provided. An included example elucidated a learner’s contradictory values on the term: “the ability to practice patient centred medicine”. This highlights that there needs to be adaptation of qualitative markers to adjust for this discrepancy. (20) Student’s biases also arise from the lack of capacity to entertain that positive outcomes can be attributable, as much as negative, to luck. (12) This skews their overall responsiveness to factors by attributing the negative to external environmental factors, with the positive imputable generally to one’s own performance and skill. (12) Moreover, bias occurs, and therefore so does resilience to feedback, when one believes that they “know enough” resulting in the discounting of information (12). This reflects their belief in their capability at some basic level to self evaluate as to whether they’re sufficiently well trained to practice in given circumstances (12).
Self assessment and perceptions
Self assessment has consistently been shown as an insufficient mechanism for skill enhancement (12), with students reported to be particularly poor self assessors (21). Feedback serves to encourage self awareness (33), refine the capacity to self evaluate and later self regulate as a doctor (29). However, it is this skewed self evaluation that may ultimately serve to hinder feedback receptiveness (4, 13). In later years, it has been shown that it is potentially the most incompetent doctors who are least cognisant of their own deficiencies (39), suggesting that this insight reflects the overall ability of the student as well. All feedback, if recognised and engaged, is appreciated and perceived throughout the filter with which students judge the clinical setting, the giver, and their own skills (13). Therefore, one must consider the learner during assessment, if the aim is to deliver feedback with which to be engaged and assimilated (13). Furthermore, students show a marked discrepancy between the skills they think they have and skills they possess in reality. Their assessment of their own performance tends to agree only mildly with that of their supervisor (40). This poses a problem to a students’ receptiveness, as the degree to which feedback is perceived as beneficial, hinges on the extent said feedback can be related to one’s own self assessment (41). Conflicting feedback stimulates an overly emotional response decreasing their overall receptiveness (4). Evaluation and feedback can be used to help students take control of their own learning (42, 43). This can particularly be seen through the use of feedback portfolios and action planning (44, 45). These have been shown to differ depending on ability. They are ultimately suited to their own capabilities, with higher achieving students setting more advanced goals (46). There are also many tensions both intra and inter individual, which are pervasive in all aspects of self assessment driven by feedback (47), and therefore serve to hinder its overall receptiveness. For example: the tension arising from dichotic nature of desiring feedback, yet dreading disaffirming feedback. (47) Multi- source feedback informs self assessment (41), but is inhibited by these above tensions (47). Other factors which inhibit accurate self assessment and therefore the receptiveness of feedback includes negative feedback, as previously eluded (48). The internal comparison of extrinsic negative feedback and self perception leads to various responses, depending on whether it serves to confirm or disaffirm. The latter results in a strong and long lasting distressing effect which may result upon adaptation and opening a different perspective (3). This occurs following the reflection upon intervention (48). It is this engagement, including reflection, that is critical in developing accurate and efficient self regulated learning (3).
Feedback framing, eliciting emotions and previous negative experience
Feedback doesn’t always lead to learning (4). The provision of feedback and the way in which that feedback is framed ultimately affects the overall relationship between educator and learner (21) Moreover, the way oral feedback is framed also influences its overall effect (49). Performance tends to increase with positive framing (49). Conversely, some methods of framing serve to be particularly demotivating, and act to inhibit learning (18, 49). Another interesting aspect of framing is that, although students still perceive that it works, the feedback “sandwich” does not appear to change actual performance (21, 50). Additionally, some students place little emphasis on feedback because of previous negative experience and therefore exhibit avoidance behaviours (28). However, this isn’t always the case. Potentially owing to the lack of an operational definition of framing (2), as previously mentioned with feedback (1), the literature appears to be mixed with regards to alternate framing in terms of both positive and negative and their respective results (2).
Further research has shown that the way in which feedback is framed and the type given ultimately affects the emotions experienced by the student. Certain emotional reactions, stimulated in order to preserve one’s ego, to a logical event, can hinder and suppress any constructive feedback creating an “insurmountable barrier” (4). Effectiveness of feedback is lowered if it is perceived to threaten the self image (15). Strong emotional reactions to feedback include those of shame and guilt. The former results from perceived criticism or negative feedback of one’s character in contrast to their behaviour under evaluation (15). This ma
y result in a negati
ve affective perception that rectifiable intervention cannot repair one’s defective identity (51). Guilt, on the other hand, does not universalise to the entire person, and thereby doesn’t lead to a destructive self worth or image (15). Communication techniques methods of framing can be employed to assist in fostering “engaged empathetic and shame resilient” students (52). Educators must ensure the acknowledgement of the presence of shame and guilt, avoid humiliation and lead learners to shame free response to error. This may occur through the leveraging of constructive feedback (52). One should also share their own experiences of shame, in order to show that learners are not alone (14). This serves to potentially decrease the overall negative experience with feedback, thereby preventing future avoidance behaviours and decreased self efficacy (15,53)
If applied to learning, shame has the capability to advocate indifference from major learning affairs, increasing the desire to quit, whereas guilt has capacity to enhance interaction and receptiveness (15). Naturally, the latter should be a primary goal. Feedback should therefore preferably accentuate certain actions learners can act upon, rather than principle fixed aspects of their personality (15,53). The provision of encouraging feedback results in increased efficacy if it is procedure driven and not
humiliating (14, 53). Humiliation, which is unfortunately worryingly pervasive in medical education (15), results in the feeling of shame and assumption that the treatment is warranted, engendered and fitting. Recent studies have shown associations between predisposition to shame and underlying depression and anxiety (15).
The method by which feedback provision is approached is of key importance, as feedback is often perceived as disapproval, further potentiating the shame or guilt response (14). An important concept to realise is that mistakes are an irrevocable part of learning. Nevertheless, the tension arising out of learning from mistakes exacerbates feelings of guilt and shame in medical training. This necessitates a more conservative approach to be employed to discuss these issues (14). Differentiating between right and wrong is hard if a career determines who you are and therefore learners at all stages of career are prone to the shame response (14). Health care professionals are particularly vulnerable to negative affective experiences, such as shame, stemming from prioritising perfection and their responsibility in patient-centred care (14). Framing of feedback, consequently is a necessity in order to overcome the feeling of failure (54).
Relationship
An important new feature in the literature suggests that it is who, as much as what or how, that highlights the understanding and engaging aspects of feedback (7, 29). Social relationships determine how feedback is both provided and received (21). “Agentic Engagement” and “Proactive Recipience” (11) are emerging topics in the field of feedback, especially with regards to the concept of educational alliance (9). This is a collaborative framework between student and educator (75). Before the introduction of said alliance educators were perceived to continually fall short in the provision of effective feedback (29). Gaps were pervasive in medical students’ satisfaction as educators missed opportunities to recognise conduct deficiencies and aid an individual in grasping their potential (29). Previous literature was focused on “unidirectional content delivery” and a learners’ passive role in passive receptiveness of the content (55). It is through this new educational alliance framework that educators may develop a more intricate appreciation of the context and relationship with which feedback receptiveness is most effective (55). This new active bidirectional negotiation (4), with the proposition of agendas, (52) and fostering an educational relationship (55) increases engagement as learners are fully invested in their learning outcomes. Through this new partnership, motivation can be enhanced as a result of the satisfaction of a prime psychological need according to self determination: relatedness (21).
Fundamentally, the perception of feedback (25), and the educators divulging it, ultimately determines how it is understood (25), thereby shaping a learner’s engagement (56). One such contributing to this aspect is the perception of credibility of the source (12). This arises when the educator has the characteristics to evaluate and bestow worthy feedback. Their ability in the provision of feedback is closely linked to both their knowledge and experience. Also, the educators’ credibility is dependent on their behaviour, their perceived attention and interpersonal skills (57). This credibility has been shown to be dependent on a mutual understand between educator and student of the overall aims, roles and goals facilitating an “alignment of values” (29). Students also directly discounted feedback if its source had not directly observed their performance (12,29). Another similarly important process, was that in order for the information to be utilised, students must believe that the feedback was coming from a balanced position of beneficence and nonmaleficence (12,29). Naturally this belief requires intimate knowledge of the source and therefore a previously established strong learner-educator relationship is a necessity in this regard (12,29). It has been shown that the relationship between receptiveness of the individual and credibility of the supervisor is positive (44). Feedback is associated with high quality teaching (33, 58) and in the ever demanding and time sparse clinical setting educators should understand which activities learners appreciate (58). Unfortunately, most clinical rotations don’t support this therapeutic alliance framework: scheduling constraints limiting continuity, time pressure and other factors deny important ingredients for developing source credibility (29).
Cognitive reasoning processes
Further features which influence a students’ receptiveness include their own intrinsic motivations fears and expectations (13). Key factors in self perception showing a paradoxical relationship with feedback receptiveness include confidence, experience, and the fear of not being knowledgeable. This complex interplay can result in the increase or decrease the engagement with feedback. (12) The fear of appearing deficient in knowledge was evident in all aspects of medical training – with this fear paradoxically acting as a motivational factor, or conversely serving to hinder learning. It manifests especially in learners as they attempt to assess their capability in adverse situations. This initially arose from fundamental differences in the inherent disclosure of their intrinsic limitations in clinical practice. The consequence and humiliation (15) of said incompetence impeded their ability to ask for assistance, so much so as to reassess the risk to the patient (12). Experience was another fundamental attributor to the capability as to whether one is capable of performing a task, serving to guide one through complex situations. However, despite this, the overall quality of
experience of the knowledge acquired from it weren’t specifically mentioned. This has led to the assumption that experience alone – especially in the case of quantity and their relation to the specific task at hand, served to promote this feeling of confidence. Experience also however acted as a “double edged sword” depending on the overall outcome of said event. It primarily led to increased confidence, yet this feeling was potentially transient and insubstantial. Therefore, it is necessary to foster and maintain this sense of confidence and one such method is through the use of feedback portfolios (12). The paradoxical efficacy of confidence in the receptiveness of feedback arises from a complex interplay between its beneficial and hindering status. Confidence is undoubtedly a necessity in
order to seek feed
back (21). It has the capacity to safeguard the recipient from feedback’s potential nature critical quality. Unfortunately, however, it also exerts a deleterious effect stemming from belief that one must exude confidence. (12) Further negative attributable effects of confidence are that it may result in an over zealous discounting of feedback. Confidence is unfortunately an undependable measure of prowess, due to the inherent flaw in an individual’s capacity to self assess (12), and therefore serves to enhance resilience in a particular cohort of students.
Resisting
Despite efforts to try to increase a student’s interaction with feedback, certain personality attributes and methods of thinking contribute to making some students, particularly medical, more resistant than receptive. In an effort to protect one’s self-regard and therefore their self worth against unwelcome appraisal in a “culture of comparison”, students resist or detest feedback. This “resiliency and ego armouring” has been attributed to a student’s sense of insecurity, inadequacy and invulnerability (59). The inability to critically self assess has also been attributable to said resistance stemming from the necessity to protect self image and worth (4), and may avoid future iterations altogether.
Lack of a complete loop
Finally, it is important to note that the provision of feedback and its subsequent reception are only the initial steps in a complex loop (18). Feedback is an essential part of the curriculum which should respond to and drive learning, not separately but integrally. (18) Therefore, in order to value the true worth of feedback, it should be appreciated over time not at a single static point. Feedback should result in the acknowledgement of discrepancy, which should later be assessed. “Follow up
activities” are warranted (4). This may serve to introduce or strengthen metacognitive thinking, potentially enhancing future receptiveness to feedback (4).
Conclusion
Despite many good practices on how to create actionable feedback there is still a paucity of information on how to change students’ behaviours so that they develop from being passive recipients to active being proactive engagers (60). This is partly owing to current incorrect measures of success (4). Presently, examining the efficacy of feedback is typically aimed at measuring learners’ degree of satisfaction or improvement in their results instead of their behavioural changes (34).
According to self determination theory, current models and methods in the provision of feedback are unlikely satisfy the three psychological needs. These needs inter-relate to stimulate intrinsic motivation, thereby decreasing its overall engagement and efficacy. To a certain degree, however, competency, autonomy and relatedness are socially determined, and therefore this emphasises the already central role and relationship with the feedback provider (21).
Bing you et al (2009) emphasised three factors imputable to students which may compromise the potency of feedback:
• Students inadequacy of self appraisal
• Subduing effect of emotional responses to feedback
• Insufficiently fostered metacognitive capacity (4)
Students potentially view negative feedback as a personal attack on their self image (4). The employment of “cognitive mechanisms to protect themselves from narcissistic injury” – a “psychological immune system (12)” – is a key aspect in the resilience against feedback. (4) Trainees do not receive feedback free of emotion (21). Said resulting emotion stemming from feedback directed at this disparity, must first be tackled before the assimilation of information can commence (12). Therefore, in order to increase receptiveness, metacognitive thinking needs to be advised to be incorporated into the curricula (4) and attempts to desensitise learners to negative feedback (4). Dialogues are also proposed as methods to challenge past negative experiences (shame and humiliation) in order to prevent further hindrance of development (28). Other methods of potentially increasing learners’ receptiveness can be targeted by the production of feedback portfolios or action planning, with which their is currently little engagement (61). Current research shows that they enhance reflection, feedback seeking behaviour (45), promote self sufficiency (44) and encourage dialogue with educators (45). Furthermore, feedback portfolios enable learners to
distance from embryonic emotional reactions to analysis of performance (62) and facilitate students to evaluate and learn from their mistakes, re- instilling a sense of confidence (12). This concept offers a sustainable view: a more central role of learners, via a collaborative negotiation in determining feedback (18).