Feeling Feedback: The Role of Emotions in Feedback

Feedback is emotional. We have all experienced anger, sadness and pride after receiving feedback comments on work we cared about. How much do reviewer 2's comments on a rejected manuscript sting?! Indeed, medical education research often speaks of learners' emotions at receiving feedback information. However, when it comes to how educators work with these emotions to leverage change, we are on less certain footing. In what follows, I briefly summarise my 2025 ASM keynote in three parts. First, I present literature on feedback and emotions. Second, I seek to define emotions in relation to feedback highlighting possible expansions. Third, I offer avenues for leaning into feedback emotions. My thesis is simple: If educators and learners had better strategies for working with feedback emotions, this may enable more productive feedback conversations and less feedback avoidance. I adopt a definition of feedback as scaffolding learners to make sense of performance-relevant information for learning [1]. Emotions, I conceptualise, as multifaceted, situated and complex [2]. They are central to learning, memory, reflection and growth. I use feelings and emotions interchangeably here recognising that in certain paradigms, feelings are differentiated from emotions through language and conscious thought. In my worldview, everything is given to us through language. I have no access to biological emotions except through language and story. Feedback research has mostly examined learners' emotions as a result of feedback. Typically, they present emotions as linear responses to feedback information where positive feedback comments lead to positive emotions like happiness, pride or relief and negative comments lead to negative emotions like disappointment, frustration or sadness. Not all research treats learner emotions as passive reactions to feedback comments. For example, Eva and colleagues [3] highlight the active role of emotions in processing feedback information. They show how fear of appearing stupid might prompt certain behaviours like educator avoidance and discounting of feedback information. Strong negative emotions can interfere with learning from feedback [4]. The emotional legacy of particularly poor feedback experiences stings long after the event has passed [5]. Much less research, however, has been conducted with respect to educators' emotional experiences with feedback as compared to learners' emotions. A stand out example is the work of Dennis and colleagues [6] who studied the emotional toll of feedback on educators. They found that educators fear that feedback might upset their learners. Given the relational nature of feedback [7], even the most hardened educators must experience emotions during their feedback practices whether it is sympathy with the student and/or frustration at needing to repeat the same information. I do wonder whether the emphasis on relationships in feedback practices has had a chilling effect on feedback. Educators might avoid difficult feedback conversations for fear of disrupting the educational alliance. While we have researched feedback emotions, our frameworks for working with emotions in feedback are more limited. Famously the feedback sandwich—much like the ‘sugar-coated pill’—in its function served to disguise negative comments to make feedback more palatable [8]. This ritualised approach is perceived as tokenistic by learners and can interfere with knowledge generation. The Pendleton model started feedback conversations with the question ‘how are you feeling’ in relation to the performance and to ascertain the learner's readiness to ‘receive’ feedback information. Thus, positioning emotions as something to be wary of. The R2C2 model of coaching goes further by exploring the learner's reaction to the feedback information through asking open-ended questions [9]. I suggest we can go further still. Emotions are complex, multilayered, embodied, social and relational. There is no consensus view and a variety of theories about emotions abound. This is not simply academic; how we view emotions dictates the strategies for working with emotions within feedback conversations. A review of medical education literature identified four key discourses of feedback emotions [10]. The four discourses are physiological, psychological, sociocultural and emotionally reflexive practice. Each of these discourses positions emotions differently. The majority of papers framed emotions as physiological reactions to feedback comments, that is, as mostly linear and individualistic—to be ignored. Less than a handful were psychological, internal, where emotions were cast as something to be managed—the learner should prevent or suppress negative emotions in order to learn from feedback. The sociocultural discourse cast emotions as social, political and cultural mediators, where trust and care might support or enhance feedback conversations. And finally, emotional reflexive practice cast emotions as relational influencing feedback interpretation and use. I want to illustrate the flaw inherent in the predominant discourse of emotions and behaviours being simple linear reactions to feedback comments. Pekrun [11] identified that ‘positive’ emotions can be either activating or deactivating, similarly for ‘negative’ emotions. For example, a learner might feel relief at praise and choose not to make any further improvements or change behaviour (hence what might be characterised as a positive emotion leads to deactivation). Shame or stress typically perceived as negative emotions can be activating in terms of behaviour change. The point here is that the valence attributed to the emotion itself might not predict whether feedback is productive or not. And multiple emotions may be experienced at once. Further, the valence of an emotion is affected by how individuals view the social context in which emotions are experienced and this valence may change over time [12]. The relationship between an educator and learner forms part of the social context of feedback. Hence, the tenor of the feedback comments themselves is also appraised based on the strength of the educational alliance [13]. This research showed how the valence of the feedback comments (positive or negative) does not equate to their effect on emotions, because relationships act as a mediator. For example, a participant described an experience where an educator opened with ‘you did it all wrong’ but the learner had a positive emotional response as a result of a strong alliance, whom he described as really caring for him [13]. Therefore, any suggestion that a positive feedback comment will lead to positive emotions and therefore positive action and vice versa is too simplistic. We need to draw on a broader range of conceptualisations of emotions [14] that move beyond the individual to consider how to productively work with feedback emotions. Rather than trying to avoid or suppress feedback emotions, what if we lean into them? Ahmed [15] suggests we should look not at what emotions are, but at what they do. This turns our gaze away from only ourselves. In order to do that, we must first acknowledge the presence of emotions within clinical learning environments [16] and feedback conversations specifically [2] to understand the work they are doing. Second, we might be reflexive about our own and others' emotions and use them to chart a path [17]. Fox argued that: ‘the significance of an emotion is not as a bodily response to an event, but as a capacity to affect’ [18]. Feedback, particularly formal feedback, can intensify emotions that ‘stick with’ trainees and educators, leading to action, including feedback avoidance [2]. However, unpleasant emotions, when reflected on in a supportive and structured environment, can catalyse growth and productive action. To do this well, educators may themselves need to explicitly address the tendency to experience distress when emotions are elicited, which can lead to shutting down emotionally sensitive yet essential and constructive conversations [19]. This is also not an invitation to purposefully cause learners anxiety and distress, but to create space to discuss emotions that arise from work and feedback conversations, whatever these emotions might be. Attuning to emotions within the educator–learner dyad might help identify potential weakening of an educational alliance, or even a rupture, early and so be more readily repaired [20]. Third, we might tune into the emotional climate acknowledging that emotions circulate within the learning environment and intensify if ignored [15]. The emotional climate broadens perspectives beyond the dyad. It is defined as an overall emotional tone that is collective and socially layered [21]. A relaxed emotional climate may invite a broader range of diverse contributions and responses to questions [21]. This is likely better achieved within day-to-day informal feedback conversations, which if done well, might not need to be limited to an individual learner. Feedback is saturated with emotions—to feel is human. The medical education literature typically represents emotion in feedback as an internal state, to be managed and suppressed. Even when reflected upon these are often considered only in the context of learners' reactions to feedback. But emotions are not simply reactions to events; they shape action. Emotions serve to foster community, build trust and promote vulnerability all necessary conditions for productive feedback conversations. What if we viewed emotions as less destructive and more generative? Then feedback becomes about opening up a space to speak about and interrogate practice, an invitation for exploration of performance and emotions. I wonder, in other words, whether feeling feedback might lead to less avoidance. Rola Ajjawi: writing – original draft, writing – review and editing. The author declares no conflicts of interest.

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