Barriers and promotors in receptivity and utilization of feedback in a pre-clinical simulation based clinical training setting

Objective: Many studies have explored feedback effectiveness using interventions focused on feedback delivery. It is equally important to consider how learners actively receive, engage with and interpret feedback. This study explores how medical students receive and use feedback in pre-clinical skills training. Method: Focus group data from 25 purposively selected thirdyear medical students was thematically analysed. Four major themes and eight sub-themes related to the facilitators and barriers to feedback receptivity and utilisation to feed forward emerged from the data. Results and Discussion: Students were receptive to feedback when its purpose and content aligned with their personal objectives, when it was consistent between tutors, and when it involved developing longitudinal relationships. The clinical skills formative logbook feedback culture with a learning focus was perceived to be predictive of their future performance and they were likely to take feedback on board, emphasising the role of reflection in this process. The depth and timing of actual feedback use varied among students, and language barriers hindered decoding feedback. Students’ self-regulatory focus on the feedback process had a dominant influence on their active use of feedback. Conclusion: Incorporating learner behaviour underlying feedback use should be considered when designing interventions to promote feedback engagement, feedback literacy skills and responsibility sharing in the feedback process. Establishing a learning culture that promotes shared responsibility between clinical educators and learners enable greater control by learners over assessment and feedback processes and a commitment to behaviour change.


Introduction
Focus of feedback usage is typically aimed at the feedback provider (clinical teacher), but very rarely is the onus placed on the feedback receiver (medical student). Given that studies have shown that medical students are often not satisfied with the quality and quantity of the feedback they receive [1][2][3][4] , there is a need to better understand this phenomenon so that feedback can be made more useful to the feedback receiver. The linear transmission view of feedback from the educator to the learner, often referred to as the consumer model of education, implies that learners are passive recipients with relatively little responsibility to make feedback effective. This passive approach may explain the reduced satisfaction with feedback 5,6 . Despite evidence that the feedback providers can amend the quality of feedback they provide, that alone would be insufficient to achieve 'quality' 7 . In addition, the feedback paradox emphasised by Withey stresses how students recognise the importance of feedback and complain about its quality, yet make limited use of it 8 .
When feedback messages are conveyed from a provider to a receiver, engaging with and converting the feedback into learning activities that bring about desired change are clearly more important than simply receiving feedback 9 . Competencybased medical education supports the premise that feedback is a dialogue process, where learners understand feedback and use it to improve the quality of their work 10,11 . Receiving feedback can be a difficult, impassive act requiring honest and critical self-reflection, with a commitment to improving 12 . Medical students are often unprepared and untrained in receiving and accepting feedback, and hence fail to use feedback to inform their subsequent clinical skills performance. More needs to be done by students to take responsibility to move learning forward to close the feedback loop 13 .
Feedback is a 'double-edged sword', and the performance effects of feedback can be highly variable in that it does not always improve performance; it can, conversely, reduce performance 14

. Kluger and
DeNisi's feedback intervention theory (FIT) explains how an individual respond to feedback 14 . Attentional shifts occur, depending on the characteristics of the feedback comments, nature of the task, and personality and situational variables. According to FIT, people regulate their behaviour by comparing it to committed goals. Higgins's self-regulatory theory explains how people have two regulatory foci, namely prevention and promotion 15 . Both personality and situational variables, such as the individual's self-efficacy and task-related self-regulatory focus, as either a promotion (things people do because they 'want to', which promotes eagerness for rewards) or a prevention (things people do because they 'have to', to prevent failure), determine how the feedback recipient chooses to change 16 . When an individual's promotion regulatory focus is activated, positive feedback motivates performance more than negative feedback. When the prevention regulatory focus is activated, negative feedback motivates performance more than positive feedback.
Feedback is therefore a complex process, and the factors that make feedback effective for learning remain considerably uncertain. Feedback effectiveness critically rests on how the learner proactively receives, engages and acts upon feedback, termed the 'proactive recipience' 17 . The importance of feedback therefore lies in its impact on recipients and not only on how it is provided 18,10 . If we therefore wish students to be active feedback users, it is necessary to ask how feedback has been received, accepted and assimilated into performance. To effectively do this, numerous factors that influence learners' reception of feedback and strategies for using feedback should be analysed to confirm learner performance improvement within the feedback loop.
Prior research in medical education has outlined numerous reasons why students' use of feedback is sometimes limited 9,19,20 , but there has been inadequate systematic exploration of these barriers. As feedback processes are complex interactions, assessing learners' feedback perceptions could provide educators with an understanding of the processes explaining learner behaviour towards feedback engagement in medical education.
There is insufficient investigation and research into the different ways medical students receive and use feedback within the context of undergraduate clinical skills assessment activities 21 . This is particularly relevant to the crucial and anxious transition phase during clinical training 22 . Since most educational research studies deal with written feedback on written tasks mirroring higher education practices 19 , care needs to be taken if extrapolating the findings to other kinds of assessments, such as workplace-based clinical skills assessments. Given that competencybased medical education is changing towards constructivism 10 , investigating medical students' recognition and understanding of feedback, as well as their strategies for effectively using feedback to facilitate the feed-forward process, need to be explored. The clinical skills setting was chosen for this study, as literature suggests that medical teachers include more direct observations and are more learnercentred in their approach to feedback 23,24 . Further, finding optimal ways to support learners' use of feedback may be inadequate if merely understanding the barriers to their feedback implementation; we also need to pay attention to what learner behaviours facilitate the use of feedback. This study thus explores medical students' feedback receptivity, the characteristics of feedback behaviour that could optimise its use and, more specifically, what students actually did with the formative assessment feedback they received following directly observed clinical skills logbook assessments.

Context and setting
The study was conducted at the clinical skills laboratory at the Nelson R Mandela School of Medicine (NRMSM), University of KwaZulu-Natal (UKZN), Durban, South Africa. The school follows a six-year undergraduate, hybrid, problem-based curriculum, where three pre-clinical years precede three clinical years, reflecting an integration of the basic sciences with the clinical disciplines. At the beginning of the academic year, pre-clinical students are provided with a clinical skills logbook (Appendix 1) and a protocol with task-specific learning outcomes. Each theme runs for a period of six weeks, covering skills related to a specific body system. Students at the end of a theme are expected to demonstrate competence in conducting physical examination skills, which are specified in the module course as a DP (duly performed) requirement, using standardised/ simulated patients. The purpose of the clinical skills logbook assessment is to formatively assess students' competence in performing a skill, and to provide structured feedback that answers three questions related to the task learning goals: 1) What was done well? 2) What was not done well? and 3) What could be improved in a similar situation in the future? This is based on directly observed performance of multiple clinical tasks by multiple supervising tutors and peers throughout the skills training period within the academic year. Students are informed that instead of marks, a global rating is provided to assist them in understanding their level of mastery of the skill. This rating would be failure (approximately <50%, if core competencies are missing or unreliable); weak pass (50-59%); competence (approximately 60-80%, with core competences demonstrated and reliable); or superior performance (approximately 80%, with core competences demonstrated using confident and appropriate technique, showing good knowledge and understanding of the skill). The clinical skills logbook formative assessment runs repeatedly throughout the second and third pre-clinical years, similar to the model of longitudinal integrated clerkships 25 .

Study population
This study adopted an exploratory qualitative methodology with a purposive sample. Five focus group discussions were conducted with third year medical students, representative of their demographics and academic performance, and who had at least one year's exposure to the clinical skills formative logbook assessment feedback. Each group had five students (n=25) based on the consent and availability of the students. The use of a smaller group of participants from a common discipline provided a 'bounded environment', which can be useful for producing richer, more in-depth emerging discussions, and provides a mutual interpretation of ideas, perspectives and terms 26 . Focus groups were conducted until data saturation was reached.

Data collection
Focus groups were held for approximately 60 minutes with at least one of the researchers and a moderator. The moderator ensured neutrality in the discussion and that the findings were shaped by the participants' perspective, and not through research bias. The moderator ensured that all participants shared their experiences and perspectives. The moderator was a clinician and colleague involved in the educational activities of the clinical skills laboratory, and had no direct involvement in the research study. The sessions followed a semi-structured approach underpinned by open-ended questions. The researcher elicited the perceptions of the student cohort on their engagement with and use of clinical skills feedback, as well as conditions that promoted useful feedback. Clarification and responses were further probed as required to ensure that the content of the discussions covered the study questions. Questioning evolved according to the participants' responses. Discussions continued until saturation was reached, with no new content emerging.

Data analysis
The audiotaped focus group discussions were transcribed verbatim and qualitatively analysed using continuous systematic text condensation, a method of content and thematic analysis 27,28 . The authors read the text material several times to get familiar with the data and obtain an overall impression. The data focusing on the dialogue on participants' general perceptions of receiving and using feedback was systematically searched to identify patterns within the data. Different aspects of the feedback processes relating to learner behaviour towards feedback receptivity and use that emerged from the data were identified and coded using keywords and text chunks. The contents of each of the coded groups were condensed and summarised into themes (Table  1). With consensus of both authors, applicable subthemes were identified and derived by generalising descriptions and concepts. The themes and sub-themes, together with supporting quotations, are described below.
Ethics approval and consent to participate: Ethical approval for this study was granted (HSS/2213/017D) by the University of KwaZulu-Natal's Ethics Committee.

Results and discussion
In their discussions, participants consistently described facilitators and barriers to understanding and implementing feedback. Analysis of these discussions revealed four main themes. Within each main theme, two sub-themes related to the facilitators and barriers of feedback receptivity and use emerged, shown in Table 1. For each of the feedback processes relating to learner behaviour in Table 1, we discuss the facilitators and then the barriers to the participants' feedback receptivity and utilisation to feed forward. Each theme and sub-theme will be discussed and supported by illustrative quotes from the five focus group discussions (F1-F5).

Facilitator: Adequate 'feedback mental model'
A mental model is a representation of someone's thought process about how something works. Students' awareness and understanding of what feedback meant to them and what feedback is for them 8 , revealed aspects of their 'feedback mental model'. They described the purpose and feelings of receiving feedback as well as developing good relationships with their tutors as means of supporting their clinical skills improvement. One aspect of this was that the clinical skills feedback had the capacity to support their uptake of feedback by clearing the mind and increased their confidence and self-esteem in performing the skills:

…feedback that you get from skills clears the mind and gives us courage and confidence to apply the skills…and to improve it. [F3]
For the feedback process and feedback literacy to be enhanced, students need to both appreciate how feedback can operate effectively as well as develop opportunities to use feedback within the curriculum 29 . Some participants described more nuanced perceptions of the purpose and nature of feedback, which were associated with positive comments of satisfaction in that feedback helped them to reflect on their performance, identify their gaps and take action to improve:

It gives me a better picture on everything…on my last logbook session I saw that I lacked in sensory examination, so it helped me go back, reflect on my work and study and be able to link everything and understand better. [F4]
Maturity played an important role in students' sense of the value of feedback to self-regulate their learning 30 . Participants pointed out that feedback was becoming more relevant and taken more seriously as they progressed through the years, indicating how it motivated their situational self-regulatory focus on feedback use: Consistency between educators has often been found to be lacking, and is something that has been highlighted in previous studies 33,7,34  Murdoch-Eaton and Sargeant highlighted the role of learner maturity in decoding terminology and subsequent feedback recognition 30 .

Barrier: Inability to decode feedback message
In contrast, participants expressed particular frustration about tutors' use of complicated language when commenting on their skills performance, which may limit feedback utility. This, coupled with difficulties understanding the tutor's accent, led to misunderstanding terminology used in and meanings of verbal feedback comments. Feedback givers may expect their remarks to be readily decoded and used; however, learners may need additional intervention to decode complicated texts and language 11,36 :

Facilitator: Adequate knowledge of appropriate strategies
Though students appreciated the role of feedback to improve learning, their responses regarding their behaviour and strategies for the actual use of feedback to promote learning and autonomy were mixed and varied significantly.
Some participants mentioned a passive engagement with feedback in that they at least read the feedback comments immediately after receiving them, but only acted on them before the OSCE. Though they seemed aware of certain strategies they could use, they also recognised that they could adopt these strategies better. There was hence a situational selfregulatory focus on feedback use with exams as the driving force: Some students strived to establish the teachers' expectations and were proactive at seeking out feedback 39 :

If you have a tutor that is approachable for your logbook and you can ask them. [F1]
Students appreciated tutors assessing their selfreflection on their performance before feedback was given. They were conscious of how academics facilitated these possibilities, as it promoted their evaluative judgement to refine their internal feedback and self-regulate their learning 29 : Though our participants were conscious of strategies that they could adopt in principle, there were difficulties in appreciating these strategies in practice due to language barriers. They also discussed problems with how to use assistance. Students sometimes need more guidance for developing their shared responsibility and commitment to feedback use, than simply a request for them to make use of assistance 40 .

Facilitator: Sense of empowerment
Most participants identified autonomy with feedback. They also indicated that providing feedback to peers was empowering, and they often learnt from the shared experience and responsibility. An opportunity for comparison with the views of others engages students in improving their capacity to make sound judgments 29 :

Barrier: Sense of disempowerment
Participants spoke of reasons some students may not use feedback: they perceived never getting a better rating with a particular doctor even if they put in efforts to make changes to their performance. They were likely to ignore feedback due to a sense of learned helplessness, as it was perceived that past experience in implementing feedback had not been beneficial: Sometimes, students use the feedback to work on a difficult skill, but then they know that Dr So-and-So will never give a superior performance to show changes made from feedback they had before. [F2] Participants indicated that they experienced a challenge with implementing feedback if there was a clash in knowledge between the tutor and student, i.e. the tutor's expectation differs from the student's self-assessment of his or her performance: Bing-You and Trowbridge as well as Boileau et al. report that feedback incongruent with the learner's self-perceptions could be perceived as a personal attack and, as a result, no improvement in learner performance would occur 41,33 .
The lack of self-confidence to perform a skill can be a challenge for some lower performing students. One participant commented that feedback was not always realistic and did not reflect what she knew, though she acknowledged failing to demonstrate the skill well, due to lack of confidence: Learners often report anxiety with regard to the applicability of feedback to upcoming assessments 42 .
They often did not see the connection and relevance of using feedback between logbook assessments with upcoming new themes concerning a different body system perceived as not related to the previous themes in a modularised curriculum. The perception that individual assessments were not related can lead to "behavioural disengagement" 43  Burch et al. and Boileau et al. confirm that feedback that considered students' objectives such as problem solving significantly improved participation in patient-centered learning activities and supported development of self-regulatory skills 46,33 . The feedback that represented the basics of moving forward as medical learners to self-regulate their learning could have a more lasting effect on the students as future doctors 9 .

Facilitator: Proactivity to feedback
Students were aware that they needed to be proactive to engage with feedback and put it into action 43 . They were grateful for the formative logbook feedback sessions, and used the feedback to revise the skills before the exams to enhance their performance: As Hounsell noted, a primary interest in the grades rather than an appreciation of their performance may explain students' apparent lack of input towards feedback 47 . Many participants were aware of the need to be constructive in finding and using feedback, but their lack of volition to use feedback limits them from facilitating feedback engagement 11 . Bing-You et al. stress that students must have a "commitment to change" that requires a state of receptiveness 48 . However, it is known that a combination of grades and narrative feedback influences students' likelihood to engage 42 .

Facilitator: Receptiveness to feedback
Participants' motivation to engage with feedback often depended on the type of feedback comments as either positive or negative. Praise increased their receptiveness to feedback and to improve performance, as was acknowledged in their comments on the value of feedback. Participants were also aware of the need to use feedback for it to be purposeful: The feedback is definitely helpful and motivating, and when they tell you what you did well, it's helpful, very constructive, motivates you to make the changes. I can imagine also that the tutors will not be happy when they put in effort to give feedback and we don't use it.

[F5]
To avoid a negative emotional impact from criticism, participants mentioned that this was possible by careful control of the manner in which feedback was presented. Constructive feedback delivered with encouragement coming first to make the subsequent criticism easier to digest and cope with, can be useful: Others commented on the need for tutors to use a respectful tone and that negative things could be said in a polite language so that nobody feels offended. The use of feedback would be easier when received from someone they perceived to be facilitative rather than destructive: Defensive behaviour such as avoiding feedback without follow-up seemed to affect participants' feedback receptiveness. Academics placing the responsibility for feedback use primarily on students rather than offering a feedback follow-up, were perceived as inadequate, as learners' volition to use feedback depends on the impact feedback has on their learning.

General discussion and conclusions
Feedback must be used to encourage learning, although recipients may have difficulty engaging with it 19,40 . We therefore aimed to explore factors that affected students' receptivity to and use of feedback, how their perceptions influenced the contribution feedback made to their learning, and how to promote the productive use of feedback. In this study, medical students' perceptions of the feedback process informed their beliefs and opinions of the quality of feedback processes that underpin feedback engagement. The data highlighted several insights into key factors beyond the feedback-sender input and looked at how establishing a culture of feedback receptivity modifies future learning and practice, including self-judgment, self-regulation and reflective learning in the clinical skills setting. Knowing the factors influencing feedback implementation can assist educators to identify suitable methods towards helping students share in the responsibility for their academic and professional development.
We found that one of the key factors influencing receptivity to feedback was students' relationships with their clinical teachers. The impact of feedback relies on the interpersonal interactions and relationships developed within an institutional culture 50 . To avoid tutor inconsistency, students advocated for longitudinal tutor-learner relationships as an educational alliance 12 . Prior knowledge of students' performance permits tutors to acknowledge their progress and observe behaviour change.
Receiving feedback from a tutor they knew made the mutual trust between them valuable. This enhanced the credibility of the feedback received, as well as their engagement in the feedback process.
Participants also relayed certain difficulties with decoding feedback messages due to barriers to understanding feedback, such as tutor pronunciation of terminologies, language differences and illegible handwriting. Further, students felt one-liner feedback comments were limited and viewed as being non-actionable, as these comments did not indicate to them if they were on the right track. To address these challenges, educators need to take their share of responsibility to ensure consistency and clarity of feedback presentation, check students' understanding of the feedback message, and be transparent in identifying actions to take for improvement. However, students also need to take responsibility in seeking clarification and being better prepared to understand common medical terminologies to decode feedback messages 11,36 .
In this study, nearly all participants recognised that for learning to take place there is the need for students to take responsibility by effectively acting on feedback. This underpins the development of self-regulation 36 .
Winstone et al. indicate that students often depend on specific feedback that tells them exactly what to do 17 . To promote self-regulation, educators have a responsibility to develop practices that prevent students' dependence only on instructions, but instead to focus on developing their self-reflection and selfassessment. As stated in the study, participants were cognisant of appropriate opportunities that permitted them to share in the responsibility of giving and receiving feedback to develop their feedback literacy skills and ensure effective feedback processes. The need to seek and give feedback through peer feedback dialogue, along with teachers assessing their self-reflection on performance prior to feedback provision, provided them with chances to selfjudge their work towards improving their reflective and self-regulation learning processes. We found that students used a variety of strategies for using feedback. While some of them would usually only address their feedback towards the clinical exams, reflecting a situational self-regulatory focus 9 , others showed eagerness for being proactive. There were also students who indicated a passive engagement with feedback, mentioning no particular strategy for acting on feedback constructively, but rather referring to diffuse strategies 51 52,9 . Findings from this study reinforce the situational regulatory notion, described by Van Dijk and Kluger as well as Durning and Artino, that learning and the context in which it takes place cannot be dissociated 16,53 . They indicated the possibility of a situational regulatory focus on feedback use and the need for educators to not only consider methods of providing information to learners, but also to understand the situations in which information will or will not be used. The challenge in this respect is for educators to support students by incorporating into the curriculum activities to train students in skills of feedback implementation, such peer and selffeedback activities, to transform their cognisance into action. In addition, designing curricula that emphasise continuation and transference between assessments and learning objectives, such as feedback incorporating medical knowledge and clinical reasoning, allows feedback to offer a developmental function 33,54 . Students reported that they were more likely to use feedback opportunities that allowed them to think critically with larger agencies through integrated skills that promoted their self-evaluation and self-directed learning, which led to building learner ownership.
Our students confirmed that self-affirmation alone is not the path to professional improvement and that for longitudinal growth, honest constructive feedback is essential. In applying motivation to performancebased feedback, intrinsic motivation would have a greater influence on feedback acceptance and performance improvement 55 . To promote increased learner autonomy and to support the development of a mindset of proactive receptivity within the medical education curriculum, there is a need to focus on approaches that boost learners' intrinsic motivation rather than depending on only externally controlled motivation 56 . As suggested from the findings in this study, the sharing of responsibility between the educators and the learners in the feedback process raises learners' intrinsic motivation to devote more of their time to analysing the feedback they receive as well as to show more interest in seeking feedback and taking up offers for further dialogue around feedback while at the same time placing greater emphasis on their engagement with feedback and the educators' sustained feedback practice.
By identifying and promoting the learner behaviour underlying the enablers of feedback engagement and removing the numerous barriers to proactive feedback receptivity, we can nurture students as active feedback receivers and self-regulated learners. Achieving this would require designing feedback interventions that target learners' behavioural manifestations of feedback engagement such as enhancing their feedback knowledge, agency and motivation to use feedback. We propose that doing so should typically require a sharing of responsibility between teachers and learners within a more learnerfocused model where learners contribute equally to the feedback process by being active givers, engagers and users of feedback, rather than passive recipients. This study therefore confirms the need to shift the focus of the feedback conversation from the individual to the learning context, from instructional feedback messages to self-regulation, and from the perspectives of the feedback provider to the recipient. Establishing a learning culture that actively encourages feedback receptivity promotes a commitment to behavior change 57 and student centered approaches to learning 58 . Ultimately, it is dependent on learners to appreciate the importance of and acknowledge their responsibility for acting on feedback and above all their autonomy within the learning process.

Limitations and recommendations
The study identified the students' perceptions of helpful and counterproductive elements that affected their receptivity to feedback. In this study, there is the possibility that certain perspectives may be overrepresented and others under-represented, since only the students' perspectives could be interpreted to construct meaning. Since the feedback process is multifaceted and complex, it would be worthwhile establishing both tutors' and students' views about the factors they believed contributed to students' receptivity to feedback. Taking both perceptions into account may identify the extent to which any one is emphasised to move forward our understanding of the phenomenon of feedback. Studying different year groups would also be important in future studies.

Compliance with Ethical Standards
Competing interests: The authors Dr R Abraham and Dr V Singaram declare that they have no competing interests.

Consent for publication:
The participants in this study gave their written informed consent to take part in this study and for anonymised findings of this study to be published. Both the authors (RA and VS) have given their consent for the manuscript to be published, should it be accepted by the journal.
Availability of data and materials: The datasets used and/or analysed are available from the corresponding author on reasonable request.
Funding: This research was funded by the University Capacity Development Programme. The funding body had no involvement in the study design, data collection, analysis or interpretation. The funding body was not involved in the writing of this manuscript. The views expressed in this report are those of the authors and do not necessarily reflect those of theUniversity Capacity Development Programme.
Authors' contributions: Both authors have made substantial contribution to the conception, design, data collection, analysis and interpretation of data. They have been involved in drafting the manuscript and critically revising it, and have approved the manuscript for publication.