Emotion as reflexive practice: A new discourse for feedback practice and research

Abstract

Introduction

Like medicine and health care, feedback is a practice imbued with emotions: saturated with feelings relevant to one's identity and status within a given context. Often this emotional dimension of feedback is cast as an impediment to be ignored or managed. Such a perspective can be detrimental to feedback practices as emotions are fundamentally entwined with learning. In this critical review, we ask: What are the discourses of emotion in the feedback literature and what ‘work’ do they do?

Methods

We conducted a critical literature review of emotion and feedback in the three top journals of the field: Academic Medicine, Medical Education and Advances in Health Sciences Education. Analysis was informed by a Foucauldian critical discourse approach and involved identifying discourses of emotion and interpreting how they shape feedback practices.

Findings

Of 32 papers, four overlapping discourses of emotion were identified. Emotion as physiological casts emotion as internal, biological, ever‐present, immutable and often problematic. Emotion as skill positions emotion as internal, mainly cognitive and amenable to regulation. A discourse of emotion as reflexive practice infers a social and interpersonal understanding of emotions, whereas emotion as socio‐cultural discourse extends the reflexive practice discourse seeing emotion as circulating within learning environments as a political force.

Discussion

Drawing on scholarship within the sociology of emotions, we suggest the merits of studying emotion as inevitable (not pathological), as potentially paralysing and motivating and as situated within (and often reinforcing) a hierarchical social health care landscape. For future feedback research, we suggest shifting towards recognising the discourse‐theory‐practice connection with emotion in health professional education drawing from reflexive and socio‐cultural discourses of emotion.

Short abstract

This cross‐cutting edge article explores how effective feedback can be open to emotions and gauges how to leverage emotions for learning and practice.

1. INTRODUCTION

Ideally, students of health professions develop capabilities to critically evaluate and act on the feedback information they receive from academic staff, clinical educators, peers and patients. This is central to developing as professionals and lifelong learners. Like medicine and health care more broadly, feedback is a practice imbued with emotion: saturated with feelings relevant to one's sense of self and one's status within a given context. Health professions education research has not critically investigated the positioning of emotions in the feedback literature. We suggest that looking anew at this relationship should guide practitioners and researchers to account for emotions in productive ways.

The feedback literature is extensive, with many conceptualisations and practices. Common to this literature, though, is an intention that feedback leads to learning, regardless of whether feedback is conceptualised as information transmission, ¹ a process ² or co‐construction. ³ Even a cursory glance at the literature highlights that emotions within feedback practices are viewed differently. They are described as ranging along a continuum from simple linear reactions to feedback information to be avoided, ⁴ to states to be mindful of, ⁵ to affective prompts helping learners recognise and work with their feelings. ⁶ The legacy of feedback in terms of negative emotions can last for many years. ⁷ , ⁸

Various feedback models are predicated on an equal balance of positive and negative comments in order to create positive learning environments and to reduce the likelihood of defensive learner reactions. ⁹ Beyond a balance of positive and negative, others recommend that feedback ‘givers’ should focus their comments on tasks or processes, rather than the person ¹⁰ to reduce activation of a learner's ‘psychological immune response’. ¹¹ However, others note that feedback about performance is always oriented towards the self and so ‘involving the learner in feedback processes may be the healthiest way to negotiate the potential for feedback interactions to elicit emotional responses’ ² (p. 38). This is where feedback literacy comes in.

1.1. Feedback literacy

Feedback literacy is defined as the ‘understandings, capacities and dispositions needed to make sense of information and use it to enhance work or learning strategies’ ¹² (p. 1316). In short, it is about ‘making the most of feedback’. ¹³ Four components of feedback literacy are appreciating feedback, making judgements, managing emotions and taking action. This concept has become popular in a relatively short timeframe in medical education literature, with scholars calling for feedback literacy programmes to be developed for formal feedback conversations ¹⁴ and messy hospital settings. ¹⁵ , ¹⁶ Unfortunately, feedback literacy casts emotions as a threat to feedback uptake that needs to be anticipated and managed. ¹² , ¹⁷ In so doing, learners are socialised into a position of emotional vulnerability whilst ‘academics are dissuaded from challenging learners for fear of adding to their emotional traumas’ ¹⁸ (p. 36). This pathologising of emotions can clearly be detrimental to feedback including its ‘vanishing’. ⁴ Given the increased interest in feedback literacy as a mediator of feedback effectiveness, it seems timely that we systematically analyse the positioning of emotion relative to feedback to offer a more expansive perspective on emotions and their potential for shaping practice.

1.2. Emotion

In her seminal Foucauldian discourse analysis paper of medical education literature, McNaughton ¹⁹ identified three key discourses of emotion: physiological (EP; emotion is located inside the body), skill (ES; emotion as cognitive competence) and sociocultural (ESCM; emotion as a social, political and cultural mediator). She writes, ‘emotion is constituted distinctly in each of these discourses; however, they are not isolated from one another’ (p. 78). McNaughton argued that researching how emotions are ‘put to work’ in the literature makes visible the invisible emotion schemas that reproduce problematic practices. Discourse can be defined as ‘practices that systematically form the objects of which they speak’ ²⁰ (p. 49). In other words, discourses are not mere representations of knowledge; they are active and constitutive of people and society. Therefore, to talk of the ‘work’ of discourses, is to seek to understand their social significance in producing ways of knowing and being, and these may be hidden, competing and contradictory.

Literature beyond health professions education introduces other discourses including emotion as reflexive practice (ERP). Olson et al. ²¹ describe emotional reflexivity as ‘a process of drawing on emotions to, potentially, chart a unique path’ (p. 2), thus making our way emotionally and relationally through the world. What this discourse potentially attunes us to in feedback is how a learner might interpret and respond to their own and their supervisors' emotions to navigate a path of learning between their own goals and those of a training programme. These four discourses formed the backdrop of our critical review, in which we aimed to examine the range of discourses of emotion and the work the different discourses do (what it makes possible or not possible) to open new agendas for thinking about and researching emotion in feedback. We asked:

1. How are emotion discourses presented in the feedback literature?

2. How do the assumptions underpinning these emotion discourses shape our conceptualisation of (and how they intersect with) feedback?

2. METHODS

We conducted a critical review of feedback and emotion literature in the top three dominant medical education journals. A critical review ‘provides an opportunity to take stock and evaluate what is of value from the previous body of work’ ²² (p. 93). As the top journals, we judged that they represent what is acknowledged to be accepted ideas about the relationship between feedback and emotion in the field and therefore the most influential for practice.

2.1. The search

Critical reviews act as a launching point for critiquing and expanding a field. Thus, they are not meant to be exhaustive or systematic, instead they seek to identify the most significant items in the field, also described as purposive. ²³ Hence, based on journals in ‘Education, Scientific Disciplines’ listed by rank according to impact factor, we manually searched the top three journals: Academic Medicine, Medical Education and Advances in Health Sciences Education.

The search terms included ‘feedback’ AND ‘emotion’ with no variants. Feedback was variously defined in the papers, but common was the intent that feedback would lead to learning. We included empirical research papers from January 2013 to May 2020 when the search was completed. We chose 2013 as this was when the seminal paper by McNaughton ¹⁹ was published, reasoning that any effects on emotion discourses in the field might be seen following this date. We excluded opinion pieces, editorials, commentary, letters to the editor and studies that only gave cursory attention to feedback and/or emotion. Empirical papers focused on both feedback and emotion were most likely to offer a deep presentation from which to determine the relevant discourses, compared with other modes of publication. We did not conduct a quality assessment of included papers as the focus in critical reviews is the conceptual contribution of each included item. ²²

2.2. Data extraction

Data were extracted from each paper by two of the authors and then discussed by all three authors to reach consensus. We modified an existing data extraction tool used by Olson and Bialocerkowski ²⁴ and extracted the following from each article:

1. author details, including discipline, institution and location;

2. article details including title, year of publication, journal title;

3. article methodological approach; and discourses of emotion, feedback and the work of both;

4. article contribution including the theory (ies) used and the overarching argument.

2.3. Analytical framing

A Foucauldian approach ²⁵ to critical discourse analysis informed our critical review. For Foucault, ²⁰ discourse refers to language, ways of speaking and practices that systematically organise what is possible to say, think and do. A discursive approach to studying emotion and feedback ‘focuses on emotions as practices, as well as written words that are shaped historically in institutional settings through social relations. As such, discourses can be investigated as forms of social action that create effects in the world’ ¹⁹ (p. 72). Ideas about emotion have material implications for health professional training and are embedded (in)formally in curricular structures of learning and assessment, as well as in rules about what is possible for health professionals to say, do and feel. ²⁶

The research team included a feedback researcher (RA), sociology of emotions researcher (RO) and a discourse specialist (NM). We met regularly to discuss our developing conceptual understanding of each discourse and its presentation within the literature: what's taken for granted and what we miss and gain from these discourses. Discourses were multiple, overlapping and not necessarily readily untangled; for some papers, it took multiple conversations to reach consensus on the primary discourses.

3. FINDINGS

A search of the top three journals in the field yielded 59 papers of which 32 empirical research papers matched our inclusion criteria, examining feedback and emotions (7 in Academic Medicine, 17 in Medical Education, 8 in Advances in Health Sciences Education). Of these 16 oriented feedback to students (single profession or mixed), 14 included a mix of faculty and/or students, and 2 included patients in medical education feedback. We start by defining and describing how those identified as primary emotion discourses are presented in the feedback literature (Table 1), then discuss the ‘work’ of each discourse. (For a full list of papers and coded emotion discourses please see Table S1A.)

TABLE 1.

Summary of findings of discourses—Definitions and how the primary discourse is presented

Emotion discourse	Definition: How emotion is conceptualised	Application: How the primary discourse is presented in feedback literature
Emotion as physiology	Emotions are internal, universally experienced and part of our physical make‐up through biological processes.	Emotions are triggered by feedback, valenced as positive (exciting, proud) or negative (frustration, anxiety, disappointment). Emotions are antithetical to clear reasoning. 27 More sophisticated approaches to emotions in this discourse attune to: valence, contextual frame of reference and time reference to an event 28 (n = 16). 7 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41
Emotion as skill	Emotions are internal and cognitive but amenable to modification and regulation. The concepts ‘emotion management’, ‘emotion regulation’ and ‘emotional intelligence’ represent this discourse.	Emotions are cognitive responses to feedback that require processing before feedback can be acted upon. Emotions can be monitored and altered through cognitive change, such as resilience training to ‘enhance students' capacities to effectively respond’. 42 Feedback can be normalised by students to protect their self‐esteem (n = 3). 42 , 43 , 44
Emotion as reflexive practice	Emotions are relational. Individuals draw on their own and other's emotions in determining how to proceed. ERP infers a social and interpersonal understanding of emotion.	Emotions are implicated in deciding what to do in relation to feedback. Feedback behaviours are based on feeling judgements. For example, if supervisors were committed and attentive to the learner and their developmental journey, the feedback was deemed credible. 45 Emotions paired with reflection are powerful learning tools (n = 4). 45 , 46 , 47 , 48
Emotion as socio‐cultural mediator	Emotions circulate across cultural, contextual and spatial environments (a setting's affective climate). They are political: Feedback is a subjecting practice that shapes residents according to a professional community's expectations.	Emotions culturally mediate training settings. Feedback seeks to shape professional identity through attention to skill, knowledge and self‐regulating practices. Feedback is the emotionally imbued way messages about an individual's professional progress and status in the community are delivered, supported by ideas about what constitutes being professional (n = 9). 16 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56

3.1. The ‘work’ of the discourse in shaping feedback practices

3.1.1. Emotion as physiology

Half of the articles (n = 16) aligned with an EP discourse. In this discourse, emotions were cast as mostly linear and individualistic ‘reactions’ to feedback. In one study, positive emotions meant that students could integrate feedback into their learning, whereas negative emotions were said to ‘interfere’ with feedback's corrective/learning potential. ³³ Such treatment of emotions pushes learners and educators to see emotions as something to overcome. Similarly, Harrison et al. ³⁴ identified fear as a major obstacle to acting on feedback following a summative assessment, limiting learning opportunities. Others suggested feedback should be delayed until emotions have subsided. ⁷

Some articles drawing on this discourse positioned emotions, as problematic. For Chou et al. ²⁷ emotions were seen as a failing of feedback delivery, something to be avoided through creating a trusting environment where feedback's emotional protentional can be reduced. Conforti and colleagues ³⁰ cast emotions as background noise. Others were more vehement about negative emotions being a ‘hindrance’. Fokkema et al., ³² for instance, asserted that negative emotions should be anticipated and prevented or managed. In such articles, positive emotions were mostly ignored in favour of positive cognitive markers like confidence and motivation.

Three studies initially offered sociocultural definitions of feedback and learning ⁷ , ³⁸ , ⁴¹ but inevitably applied physiological conceptions of emotions in their analysis. Only one study in this discourse considered the negative effects of positive emotions on feedback. Naismith and Lajoie ²⁸ showed that positive emotions can lead to less attention to feedback and vice versa, suggesting an inverse relationship between emotional valence and attention. Performance goals and emotions such as shame, for instance, can positively influence attention, feedback uptake and feedback seeking behaviours.

3.1.2. Emotion as skill

Within the three papers employing ES as the primary discourse, emotion and feedback were depicted as having a problematic relationship. Like the previous discourse, feedback was said to have the potential to challenge self‐worth and ‘self‐confidence’. ⁴² , ⁴³ Such challenges to self‐worth were shown to be laden with negative emotions: shame and anxiety. Although it is also likely that feedback can prompt positive moral emotions, such as pride, this was not a focus of any of the studies using the ES discourse. Coping strategies used to divert the emotional ill effects of self‐worth‐challenging feedback were said to risk derailing efforts towards adaptive change. Patel et al., ⁴⁴ drawing on self‐regulated learning theory, concluded that negative emotions interrupt self‐regulated learning, by challenging learners' conceptualisations of ‘self‐worth’ and prompting coping strategies (like normalising failure) that undermine change.

Studies identified in this discourse diverged from the previous, by treating emotion as something to be managed by the individual in order to learn from feedback. Authors initiated interventions to correct coping strategies, for example, through resilience training to teach positive coping skills ⁴² or by preventing negative emotions—such as removing the normative comparators in post‐examination feedback. ⁴³ Such a discourse shifts focus away from examining the social, political and cultural features of a learning environment, which may be creating stressful relationships or emotional climates less conducive to effective learning. Although Patel et al. ⁴⁴ suggested trusting relationships between classmates may be important sources of support, where failing classmates feel it is emotionally safe to seek help, they stop short of examining (dis)trust as an emotional dimension of the medical schools' cultural environment.

3.1.3. Emotion as reflexive practice

Four articles were aligned with the ERP discourse, positioning emotions as relational, inevitable and important information requiring reflection (rather than regulation) before their impact can be realised. Within two of these four papers, ⁴⁶ , ⁴⁷ there was an implicit assumption that emotions are problematic to feedback. Such assumptions were countered but still present. Kerins et al., ⁴⁷ for example, suggested medical educators should remain alert to the potential negative effects of emotions from feedback (e.g., anxiety and guilt) but went on to assert: ‘rather than striving to avoid the possibility of negative emotions in their learners’, such findings suggested the benefits of ‘acknowledging their presence and utilising their power’ ⁴⁷ (p. 271). When anxiety, fear, guilt and shame are experienced by learners in a supportive setting, and handled in a way that promotes reflection, such emotions were said to foster potentially powerful transformative learning. Within articles using this discourse, emotions were cast as unavoidable everyday experiences that should be handled carefully and harnessed (through reflection) so that they can be useful to the learning experience.

The ERP discourse also seems to support an approach to emotionally imbued learning that recognises multiplicity in role models, feedback and sources of feedback (tools, supervisors). In the Karnieli‐Miller et al. ⁴⁶ study, for example, an ERP discourse underpinned an appreciation of feedback (and feedback in the form of one's emotions about an experience) as useful to more than figuring out the ‘right’ way to break bad news but as useful to figuring out what kind of health care professional one wants to be. Similarly, in Rietmeijer et al.'s ⁴⁸ and Telio et al.'s ⁴⁵ studies, ERP supports an appreciation of feedback as embedded within various emotionally imbued relationships—where feedback's perceived credibility and reception depends on the relationship between a particular supervisor and student.

Rather than being disruptive to an information exchange process, the ERP discourse positions emotions as helpful to feedback. Emotions give feedback meaning, weight and intensity—deepening the effects of feedback and learning. If feedback provides information that indicates individuals are not who they think they are or want to be, they feel unpleasant social emotions that, if given time and reflected on in a structured way and safe environment, can prompt productive action.

3.1.4. Emotion as socio‐cultural

Nine articles drew on an ESCM discourse with feedback and emotions depicted as everyday practices within professional cultural worlds. In these articles, social relationships and cultural climate necessarily influenced feedback's emotional impact on learners. For example, Watling et al. ⁵⁶ found that when criticism was normalised within a culture, its emotional impact was dampened; when it was unexpected, its emotional impact was more acute. The embedded understanding of emotion within this discourse meant authors often resisted decontextualised and valenced assessments of emotions as positive or negative to feedback practice. Davis and colleagues, ⁴⁹ for instance, concluded that despite some students' descriptions of negative experiences with dignity violations by supervisors, increased learning outcomes were reported.

Several common elements across articles, aligned with an ESCM discourse, fostered an understanding of feedback as a phenomenon experienced emotionally in relation to collective processes of place and profession. First, context and emotion—with trust the cardinal supporting emotion ¹⁶ , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁶ —were seen to be intertwined in feedback processes: sharing specific, observable information for the learner's benefit as a professional not just for assessment of skills. For example, in La Donna et al., ⁵⁴ cultural factors facilitating trust were recognised as contributing to a students' attitudes towards feedback as part of their professional formation and subsequent motivation to internalise information that may be difficult to hear. Here assessment settings, with their hierarchical relationships, and more level professional development settings were contrasted, emphasising the impact of place on emotions, relationships and feedback's meaning.

Second, feedback was premised on a longitudinal relationship with the feedback provider allowing for mutual goals to be set, addressed and negotiated. Care was the cardinal supporting emotion. ⁴⁹ , ⁵² , ⁵⁴ For example, feedback conversations allowed residents to feel emotionally supported and ‘cared for’ in ways they did not experience with other supervisors. Voyer et al. ⁵² stated that residents felt these ‘… relationships developed on a more equal footing than those they typically experienced … and hence allowed for more honest conversation’ (p. 950).

Third, feedback that allowed for mistakes without fear of losing face were particularly valued by scholars adopting the ESCM discourse: recognising human failure as a shared experience, not an individual trait. Confidence was the cardinal supporting emotion. ⁴⁹ , ⁵⁰ , ⁵¹ The student–supervisor relationship has the potential to support student confidence through feedback conversations that are not evaluative but informative, shared for the benefit of student improvement. Students experienced emotional struggles as positively impacting their learning and their growth as professionals. As one student stated, ‘Throwing us in the deep end was great for my confidence in the long run and I soon realised this was an amazing learning opportunity where we didn't have to get everything right …’ ⁵⁰ (p. 70).

4. DISCUSSION

This is the first review to critically analyse discourses of emotion in studies of feedback practices in health professions education. Findings depict four overlapping discourses existing on a continuum, ranging from individualistic to social: (1) emotion as physiology, (2) emotion as skill, (3) emotion as reflexive practice and (4) emotion as socio‐cultural mediator. Our findings extend discourses of emotions to include ERP, which has not yet featured in health professions education research, and we identify how each discourse influences feedback practice.

The EP discourse reinforces traditional mind–body dualism binaries, ⁵⁷ casting emotion as a positive or negative physical (body) response to (mind) feedback that either facilitates incorporation of feedback into one's practice or undermines this process. Such conceptualisations dominated, with half of all the articles employing this discourse. These articles, however, work to pathologise negative emotions and ignore the reality that emotions are part of everyday life. Further, they reinforce outdated and simplistic understandings of emotion ⁵⁸ and the relationship between emotion and feedback, such as emotions being anathema to processing feedback information.

The ES discourse extends EP depictions by focusing on emotion regulation skills. Coping strategies used to protect self‐esteem from emotions are cast as threats to learners acting on feedback. This discourse suggests that with effort, leaners can manage emotions so they do not hinder feedback processes. However, it stops short of examining learning environments. In limiting the scope, an ES discourse pushes us to see individual learners' self‐esteem, associated emotions and their coping strategies as the problem when feedback goes awry. This conception shields teachers and institutions from recognising relationships and the learning environment as complicit. Although authors working within this discourse acknowledge that their conception of emotion may be limited, and that more socio‐cultural understandings of the relationship between emotion and feedback may be relevant, they situate a cognitive approach as a relatively straightforward way to address the ‘problem’ of learner emotions.

The ERP discourse expands the scope of emotions beyond the individual learner. This discourse pushes us to appreciate the relationality of feedback and emotions and see emotions as foundational to feedback. It is not just that the feedback is emotional; the relationships underpinning feedback processes are also saturated with feelings. Such feelings provide important information within feedback practices, but ERP does not include the power relations that are ever present in feedback interactions. ⁵⁹

The ESCM discourse broadens the scope furthest to place emotions and feedback within professional environments, acknowledging that cultures and hierarchies influence emotions related to feedback. In this discourse, feedback contexts—relational, cultural and affective—are central to feedback processes. Trust, care and confidence in a learner's professional development are particularly valued in the intersecting feedback–emotion complex.

Building on these findings, we call for a new research and practice agenda within health professional education that acknowledges the work of emotion discourses. Such an agenda moves beyond mind–body dualism and tokenistic acknowledgement of emotion as relational. It takes up a call to consider emotions as inevitable (not pathological), as potentially paralysing and motivating and—importantly—as relational and situated within a hierarchical feedback and health care landscape. Drawing from both ERP and ESCM, such an agenda moves us towards an appreciation of emotions as relational and embedded within feedback, environments and socio‐cultural power dynamics.

4.1. Limitations of the data set and our study

Discourses of emotions and feedback do not exist in discrete categories. Indeed, most articles could be aligned with a primary and secondary, sometimes multiple secondary, discourses (see Table S1A). All cartographic exercises are imperfect—but they offer a useful heuristic for understanding topographical and theoretical distinctions; ‘Piecing elements together and assessing the divergences in forms of data, reveals various meanings during analysis offering a richer understanding of the knowledges at play’ ⁶⁰ (p. 172). In our analyses, we noted how slippery the discourses were, requiring multiple conversations interpreting authors' words. We also noted authors' attempts to shift conceptualisations of emotion (and feedback) away from individualistic constructs. Such attempts were often sincere but not sufficient, leading to a hodgepodge of contradictory, competing discourses and conceptualisations, involving at once an understanding of emotions as problematic, inevitable and useful. Instead, we call for clear, aligned and critically aware understandings of the differing conceptualisations of emotion: the discourse‐theory‐practice nexus. The discourses presented in Table 2 offer a useful heuristic to this end.

TABLE 2.

Discourses of emotion

Discourse	Emotion as physiology	Emotion as skill	Emotion as reflexive practice	Emotion as socio‐cultural mediator
Theoretical positioning	Positivism	Behaviourism/cognitivism	Contemporary modernism	Sociocultural/social constructivism; critical
Theoretical choices	Biomedical	Sociological to psychological	Sociological	Emotional geography to critical theory
Concepts/statements of truth	Positive information equates to positive emotion; valence is crucial; emotions are in one's body	Emotion regulation can be learned; emotions are inside one's head, agentic to doing things	Emotions are multiple and relational, co‐occurring within and between individuals	Emotions are imbued within collaboratively constructed practices; they radiate in the environment
Subject positions—who governs this discourse?	Scientists	Coaches, trainers	The self—taking a stance	Community, leaders, distributed
Material objects signifying this discourse	Cortisol measurements, surveys, checklists, emotion questionnaires	Training guidelines, self‐assessments, checklists, surveys	Acknowledgement of emotion in decision‐making, learning journals, learning plans	Acknowledgement of moods, spaces invoking comfort, professional codes
What does it make (im)possible regarding feedback	Negative emotion is problematic and must be prevented, contained or ignored for learning to take place	Emotion must be regulated or managed by the learner for feedback to be effective and useful	Emotions are central to deciding how to engage with feedback; emotions as transformative and powerful	Relationships imbued with culturally shaped and socially reinforced emotions undergird feedback and professional identity formation

4.2. Implications for feedback and feedback literacy

Emotions are not noise in the background to be ignored as conceptualised in the majority of papers; they are not merely internal but between and around us. Effective feedback can be open to emotions, gauging how to leverage them for learning and practice. Emotions are not anathema to reasoning but fundamental and connected. ⁵⁷ , ⁵⁸

We suggest that health professions education scholars shift the dialogue in this space away from simplistic understandings of positive emotions as good for feedback and negative emotions as bad for feedback. The pedagogy of discomfort, ⁶¹ for example, highlights the power of negative emotions for learning. Shame, guilt and pride are powerful prosocial emotions that teach learners what (not) to do in given settings. ⁶² Rather than problems to ignore or manage, emotions are resources to excavate and use reflexively in time.

In making such a shift, health professions education scholars should proceed with caution, as even when feedback was conceptualised as a sociocultural phenomenon, EP discourses often crept in. Such narrow conceptualisations of emotion led to a narrowing of feedback practices. Critical education scholars ⁶³ , ⁶⁴ , ⁶⁵ and emotions scholars have contributed an understanding of emotion as socio‐cultural practice and reflexive labour. ⁶⁰ , ⁶⁶ However, there has been little uptake of these more recent conceptualisations of emotion within health professions education feedback literature. As illustrated in this critical review, most studies continue to maintain debunked emotion binaries ⁶⁷ and concordantly reductive approaches to conceptualising emotion.

Feedback literacy, most often conceptualised as a skill, currently aligns best with the ES discourse. We suggest that the development of feedback literacy is dependent upon the social relations and learning environment within which feedback is situated and encourage feedback scholars to adopt ERP and ESCM discourses of emotions. This requires a philosophical and methodological shift away from positivist searches for universal truths towards an appreciation of the multiple, intersecting webs of relationships that inform feedback as a professionalising process and the importance of emotion to professional knowledge acquisition and identity formation.

5. CONCLUSION

We analysed the different ways emotion is discursively positioned in feedback studies and its intersections with feedback practices and experiences in health professions education. We found emotions and feedback to be socially and discursively dynamic. Research attending to emotion in health professions education should consider the consequences of the discourse‐theory‐practice nexus, acknowledging that chosen emotion discourses impact on feedback. Keeping emotion discourses at the forefront of research should lead to deeper appreciation of the connections between emotion and feedback, beyond individual learners. The invitation in our paper is for researchers to consider how emotion and feedback practices can be understood multi‐logically with sometimes overlapping discourses in order to foster reflexive understanding, discussion and prompt practice change.

ETHICS STATEMENT

Ethical approval was not required for this critical literature review.

CONFLICT OF INTEREST

We have no competing interests to declare.

AUTHOR CONTRIBUTIONS

RA and RO conceived the original project. RA, RO and NM were involved in the design of the work, analysis, interpretation and writing/drafting of the manuscript. All authors approve the final version.

Supporting information

Table S1. A: List of included feedback papers and coded primary and secondary discourses of emotion.

Ajjawi R, Olson RE, McNaughton N. Emotion as reflexive practice: A new discourse for feedback practice and research. Med Educ. 2022;56(5):480-488. doi: 10.1111/medu.14700