The Practice of Feedback in Health Professions Education in the Hierarchical and Collectivistic Culture: a Scoping Review

Abstract

The global trend in student assessment is moving towards outcome-based assessment that requires multiple systematic data points and continuous feedback. However, in hierarchical and collectivistic cultures, one-way communication is practised more often, leading to less dialogical feedback. This scoping review explored feedback practice in Asian educational setting. Based on the 17 articles selected, the findings were categorised into four themes, i.e. inhibiting or facilitating factors of feedback, influences of cultural factors on feedback, discrepancies between students’ and teachers’ perceptions of feedback and impact of feedback. Hierarchical and collectivist cultural aspects, such as preference for group feedback, are pertinent to feedback practice, which likely influence the readiness for programmatic assessment.

Appendix 1 List of included articles and related findings

Article details	Study focus and meaningful findings	Readiness for feedback
Theme: Inhibiting or facilitating factors of feedback
Chaou, C.H., Monrouxe, L.V., Chang, L.C., Yu, S.R., Ng, C.J., Lee, C.H., Chang, Y.C. (2017). Challenges of feedback provision in the workplace: a qualitative study of emergency medicine residents and teachers. Medical Teacher. 39(11):1145–1153. https://doi.org/10.1080/0142159X.2017.1366016	• Competing interests between the need to provide feedback and clinical duties in a real, busy clinical setting, represented by an emergency unit setting • There are ‘thresholds’ for delivering feedback in a busy clinical setting, and these thresholds are influenced by the factors of teachers, residents, and context	Overall, residents (students) and teachers are ready for feedback in a busy clinical setting; however, the provision of feedback may compete with patient care responsibilities
Mitra, N.K., Barua, A. (2015). Effect of online formative assessment on summative performance in integrated musculoskeletal system module. BMC Medical Education. 15:29. https://doi.org/10.1186/s12909-015-0318-1	• The use of an online (computer-based) formative Multiple Choice Question (MCQ) with automated feedback led to increases in summative assessment performance • Students with higher academic ability attending the online formative tests obtained higher scores compared to a similar group attending the paper-based formative tests	High-achieving students may be more receptive and responsive towards feedback, thus gaining more benefit from the online formative tests. The feedback in the formative tests facilitates students’ self-regulated learning
Sudarso, S., Rahayu, G.R., Suhoyo, Y. (2016). How does feedback in mini-CEX affect students’ learning response? International Journal of Medical Education. 7:407–413. https://doi.org/10.5116/ijme.580b.363d	• In the Mini-CEX setting under study, the feedback provided influenced students’ learning responses through various internal processes • External factors such as the consequences of the Mini-CEX affect how students respond to feedback and their action plans	Given that external factors such as consequences affect the students’ responses, it can be concurred that students are not fully ready for feedback
Fu, R.H., Cho, Y.H., Quattri, F., Monrouxe, L.V. (2019). 'I did not check if the teacher gave feedback': a qualitative analysis of Taiwanese postgraduate year 1 trainees’ talk around e-portfolio feedback-seeking behaviours. BMJ Open. 9(1):e024425. https://doi.org/10.1136/bmjopen-2018-024425	• The study identified inhibiting and facilitating factors for feedback-seeking behaviour of foundation-year doctors (trainees) in relation to e-portfolio development • These factors are learner-related, teacher-related, process-related and technology-related	When the ‘value’ of feedback is high, then trainees will seek feedback. Therefore, when the facilitating factors are more prominent than the inhibiting factors, the level of feedback-seeking behaviour will be higher (trainees are ready to seek feedback)
Yang, X., Xie, R.H., Chen, S., Yu, W., Liao, Y., Krewski, D., Wen, S.W. (2019). Using video feedback through smartphone instant messaging in fundamental nursing skills teaching: observational study. JMIR Mhealth Uhealth. 7(9):15,386. https://doi.org/10.2196/15386	• The use of a smartphone-based video feedback approach increased nursing students’ performance in the skills of bed making, aseptic procedure, vital sign measurement and oxygen therapy	It is proven that teachers can deliver video-assisted feedback that can improve students’ performance; thus, students are ready to receive and integrate feedback into their performance. However, the study shows that for more sophisticated skills, video feedback may not be useful because are not yet clear
Theme: Influences of cultural factors on feedback
Suhoyo, Y., Schönrock-Adema, J., Emilia, O., Kuks, J.B., Cohen-Schotanus, J. (2018). Clinical workplace learning: perceived learning value of individual and group feedback in a collectivistic culture. BMC Medical Education. 18:79. https://doi.org/10.1186/s12909-018-1188-0	• Group feedback is delivered more often and has higher learning value • Group feedback involves more action plans compared to individual feedback, whereas individual feedback focuses more on the weaknesses of students’ performance	Students and specialist teachers are ready to give feedback but vary in terms of the type and domain of feedback according to the relevant influencing factors. Students perceive group feedback as having higher learning value
Kim, E.J., Lee, K.R. (2019). Effects of an examiner’s positive and negative feedback on self-assessment of skill performance, emotional response, and self-efficacy in Korea: a quasi-experimental study. BMC Medical Education. 19(1):142. https://doi.org/10.1186/s12909-019-1595-x	• Feedback provided to the students impacted students’ self-efficacy, emotional state, and self-assessment • Negative feedback results in more accurate self-assessment but triggers lower self-efficacy and negative emotional responses	Students may not be fully ready to receive negative feedback since it damages their self-efficacy and emotional responses, which will lead to the inability to improve their performance. Students’ perceptions and understanding of feedback may not be accurate and teachers may not be fully ready to deliver feedback in a way that could enhance students’ performance
Kim, J.H., Kim, Y.M., Park, S.H., Ju, E.A., Choi, S.M., Hong, T.Y. (2017). Focused and corrective feedback versus structured and supported debriefing in a simulation-based cardiac arrest team training: a pilot randomized controlled study. Simulation in Healthcare. 12(3):157–164. https://doi.org/10.1097/SIH.0000000000000218	• There were no significant differences between the methods of debriefing (between the focus and corrective feedback group and structured and debriefing group) in terms of the team dynamic and team clinical performance scores • A possible explanation for this finding is the culture of Asian students, wherein students are not comfortable communicating with facilitators in structured and debriefing groups	Students are not ready for two-way communication feedback that facilitates and encourages self-assessment and reflection
Suhoyo, Y., Van Hell, E.A., Kerdijk, W., Emilia, O., Schonrock-Adema, J., Kuks, J.B., Cohen-Schotanus, J. (2017). Influence of feedback characteristics on perceived learning value of feedback in clerkships: does culture matter? BMC Medical Education. 17(69). https://doi.org/10.1186/s12909-017-0904-5	• The influence of collectivistic and hierarchical culture on how medical students perceive the characteristics of feedback in the Mini-CEX setting and how these characteristics influence their perceived learning value of feedback • In this culture, ‘mentioning strength’ does not influence the perceived learning value of feedback, which is likely due to the expectations of students for teachers to tell them what they need to do or improve • ‘Comparing performance to a standard’ is a characteristic that is not frequently used, perhaps due to the goal of feedback delivery in collectivistic and hierarchical cultures, which is to correct errors; thus, teachers prefer to just communicate their expectations • In this culture, feedback from specialists is valued more, likely due to the importance of hierarchy	Both teachers and students may not be fully ready to deliver and receive feedback. The factors influencing their preparedness are closely related to the collectivistic and hierarchical culture (high power distance)
Oktaria, D., Soemantri, D. (2018). Undergraduate medical students’ perceptions on feedback-seeking behaviour. Malaysian Journal of Medical Sciences. 25(1):75–83. https://doi.org/10.21315/mjms2018.25.1.9	• The factors inhibiting or promoting undergraduate medical students’ feedback-seeking behaviour were identified in this study • Understanding these factors will be beneficial for teachers to apply teaching strategies that can encourage students’ feedback-seeking behaviour, for students to practice the skills of seeking feedback, and for the institution to create a conducive atmosphere for feedback-seeking behaviour	Students are not ready to seek feedback for several reasons, such as the fear of getting negative comments from teachers, the existence of external motivations to seek feedback (for example, to impress others) and the reluctance to ask the teachers for feedback due to the hierarchical culture
Oseni, Z., Than, H.H., Kolakowska, E., Chalmers, L., Hanboonkunupakarn, B., McGready, R. (2017). Video-based feedback as a method for training rural healthcare workers to manage medical emergencies: a pilot study. BMC Medical Education. 17(1):149. https://doi.org/10.1186/s12909-017-0975-3	• Video-assisted feedback contributes to improved performance in clinical knowledge, confidence, and quality of teamwork in the setting of medical emergencies • Video-based feedback is also more appropriate for use in the culture where the study was conducted because feedback delivered directly by the trainer may be regarded as criticism	Students’ performance is influenced and improved through the video-based feedback provided in the study; thus, it can be implied that students are ready to receive feedback delivered in this format. However, it is important to note that students need to be more prepared for and responsive to feedback delivered through other formats, such as direct verbal feedback
Theme: Discrepancies between students’ and teachers’ perceptions upon feedback
Yanting, S.L., Sinnathamby, A., Wang, D., Heng, M.T.M., Hao, J.L.W., Lee, S.S., Yeo, S.P., Samarasekera, D.D. (2016). Conceptualizing workplace-based assessment in Singapore: undergraduate Mini-Clinical Evaluation Exercise experiences of students and teachers. Ci Ji Yi Xue Za Zhi. 28(3):113–120. https://doi.org/10.1016/j.tcmj.2016.06.001	• Discrepancies between students and teachers on the perceptions regarding feedback in the Mini Clinical Evaluation Exercise (Mini-CEX) setting • Students are more receptive to feedback compared to when they were still at a junior level	Interestingly, there are discrepancies between the perceptions of students and teachers, some of which are contradictory; for example, teachers felt that students were defensive when given negative feedback but students did not agree with that perception. Thus, these discrepancies may hinder readiness to receive and deliver feedback
Kim, E.J., Lee, K.R. (2019). Effects of an examiner’s positive and negative feedback on self-assessment of skill performance, emotional response, and self-efficacy in Korea: a quasi-experimental study. BMC Medical Education. 19(1):142. https://doi.org/10.1186/s12909-019-1595-x	• Feedback provided to the students impacted students’ self-efficacy, emotional state and self-assessment • Negative feedback results in more accurate self-assessment but triggers lower self-efficacy and negative emotional responses	Students may not be fully ready to receive negative feedback since it damages their self-efficacy and emotional responses, which will lead to the inability to improve their performance. Students’ perceptions and understanding of feedback may not be accurate and teachers may not be fully ready to deliver feedback in a way that could enhance students’ performance
Prastiyani, N.H.N., Felaza, E., Findyartini, A. (2020). Exploration of constructive feedback practices in dental education chairside teaching: a case study. European Journal of Dental Education. 24:580–589. https://doi.org/10.1111/eje.12539	• There are three main themes related to feedback provision in the setting of chairside teaching, which are ways to provide feedback, challenges in feedback provision and challenges in feedback follow-up	The factors identified in the study showed that perceptions regarding feedback differed between students and teachers. These differences in perception may cause the goals of feedback to not be achieved
Nugraheny, E., Claramita, M., Rahayu, G.R., Kumara, A. (2016). Feedback in the nonshifting context of the midwifery clinical education in Indonesia: a mixed methods study. Iranian Journal of Nursing and Midwifery Research. 21(6):628–634. https://doi.org/10.4103/1735-9066.197671	• The non-shifting context of midwifery education calls for more integrated feedback, which is feedback delivered based on the observations of students when they have been performing all activities (for example, history taking, physical examination and midwifery care). The context also allows for more intensive feedback, given at any time when students and supervisors are available	Teachers/supervisors are not ready to provide feedback that is in accordance with guidelines. Expectations concerning feedback also differ between teachers and students
Alhaqwi, A.I. (2012). Importance and process of feedback in undergraduate medical education in Saudi Arabia. Saudi Journal of Kidney Disease Transplant. 23(5):1051–1055. https://doi.org/10.4103/1319-2442.100949	• Undergraduate medical students demonstrated positive perceptions of feedback, although they also perceived that they did not receive feedback regularly	Students can identify the needs and importance of feedback; however, in reality, they do not receive as much feedback as they expect. Thus, students are likely to be ready to receive feedback but teachers may not be as ready as expected to deliver feedback
Theme: Impact of feedback
Alkhateeb, N.E., Al-Dabbagh, A., Ibrahim, M., Al-Tawil, N.G. (2019). Effect of a formative Objective Structured Clinical Examination on the clinical performance of undergraduate medical students in a summative examination: a randomized controlled trial. Indian Pediatrics. 56(9):745–748. https://doi.org/10.4103/efh.EfH_31_17.pdf	• Participation in a single formative Objective Structured Clinical Examination (OSCE) did not have a positive impact on the improvement of summative OSCE scores	Feedback was available in the formative OSCE; however, it did not affect students’ performance. The quality of the feedback may reflect the teachers’ ability to give feedback and hinder students’ receptiveness towards feedback
Mitra, N.K., Barua, A. (2015). Effect of online formative assessment on summative performance in integrated musculoskeletal system module. BMC Medical Education. 15:29. https://doi.org/10.1186/s12909-015-0318-1	• The use of an online (computer-based) formative Multiple Choice Question (MCQ) with automated feedback led to increases in summative assessment performance • Students with higher academic ability attending the online formative tests obtained higher scores compared to a similar group attending the paper-based formative tests	High-achieving students may be more receptive and responsive towards feedback, thus gaining more benefit from the online formative tests. The feedback in the formative tests facilitates students’ self-regulated learning
Raut, A.V., Gupta, S.S. (2019). Reflection and peer feedback for augmenting emotional intelligence among undergraduate students: a quasi-experimental study from a rural medical college in central India. Education for Health (Abingdon). 32(1):3–10.	• Peer feedback and reflection, as personal introspection methods, can help improve undergraduate medical students’ emotional intelligence • Medical students still have difficulty in conducting reflection due to limited protected time to reflect • Acceptance of peer feedback improved when students were assured that peer feedback is not a ‘fault-finding’ activity but rather a self-improvement process	Students will be ready to reflect and accept peer feedback when they have been assured that the processes are for self-improvement, not merely pointing out mistakes; thus, it is important for teachers to emphasise this and support the students
Yang, X., Xie, R.H., Chen, S., Yu, W., Liao, Y., Krewski, D., Wen, S.W. (2019). Using video feedback through smartphone instant messaging in fundamental nursing skills teaching: observational study. JMIR Mhealth Uhealth. 7(9):15,386. https://doi.org/10.2196/15386	• The use of a smartphone-based video feedback approach increased nursing students’ performance in the skills of bed making, aseptic procedure, vital sign measurement and oxygen therapy	It is proven that teachers can deliver video-assisted feedback that can improve students’ performance; thus, students are ready to receive and integrate feedback into their performance. However, the study shows that for more sophisticated skills, video feedback may not be useful because are not yet clear
Oseni, Z., Than, H.H., Kolakowska, E., Chalmers, L., Hanboonkunupakarn, B., McGready, R. (2017). Video-based feedback as a method for training rural healthcare workers to manage medical emergencies: a pilot study. BMC Medical Education. 17(1):149. https://doi.org/10.1186/s12909-017-0975-3	• Video-assisted feedback contributes to improved performance in clinical knowledge, confidence and quality of teamwork in the setting of medical emergencies • Video-based feedback is also more appropriate for use in the culture where the study was conducted because feedback delivered directly by the trainer may be regarded as criticism	Students’ performance is influenced and improved through the video-based feedback provided in the study; thus, it can be implied that students are ready to receive feedback delivered in this format. However, it is important to note that students need to be more prepared for and responsive to feedback delivered through other formats, such as direct verbal feedback