Cultural influences on non-Western health profession trainees seeking and receiving feedback: A Scoping Review

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However, most literature in this area originates in Western contexts, leaving a significant gap in understanding how Cultural factors influence feedback practices elsewhere. This scoping review focuses on Asian contexts, where Cultural values and educational traditions shape the ways in which feedback is sought, provided, and received. The review explores how Culture in non-Western settings influences health professions trainees’ engagement with feedback during clinical training, as well as how supervisors' feedback practices are influenced by Cultural contexts. Methods : Four databases — CINAHL, ERIC, MEDLINE and PsychINFO — were searched. The search, conducted up to June 2024, yielded 1241 citations, with an additional 51 identified through citation searching. Thirty-seven studies met inclusion criteria and were analysed. A coding framework was developed and iteratively refined through team discussions to ensure analytic rigour. Results : The review identified three key, but interconnected, themes. 1) Impact of Culture: Culture particularly power distance and collectivism, strongly influenced how feedback was perceived and enacted. 2) Diverse perspectives and preferences about the place of feedback: Trainees had diverse perspectives and preferences regarding the place of feedback. The role of group versus individual feedback appeared to be a significant difference from existing literature focussed on Western experiences. 3) Feedback is seen as error identification, influenced by hierarchy and workload: Rather than fostering learning, feedback is viewed as shaped by hierarchical relationships and competing service demands. Conclusions : Feedback is valued by health professions trainees in Asian contexts, but its conception and practice differ from those typically described in existing literature (primarily of Western origin). Cultural dimensions such as high power distance and collectivism contribute to variations in how feedback is sought, delivered, and understood. Recognising and adapting to these cultural influences is crucial for designing feedback practices that are meaningful and educationally effective in non-Western settings. Feedback Culture Cultural difference Asia Health Professions Education Medical Education Students Health Occupations Clinical clerkship Figures Figure 1 Figure 2 Background Feedback plays a key role in learning and professional development for health professionals ( 1 – 7 ). Much of the existing literature is grounded in Western educational contexts ( 1 – 3 , 8 – 18 ), leaving a gap in our understanding of how feedback is conceptualised, sought, and used in non-Western contexts. This presents a significant gap, particularly in relation to Asian countries, where Cultural values and educational traditions may shape feedback dynamics in ways that differ from Western norms. What constitutes feedback in one Culture may not hold the same meaning in another. This raises important questions: Do Cultural norms shape how trainees seek and interpret feedback? If so, what are the implications for the development of clinical competence in Asian contexts? In an increasingly globalised educational landscape, understanding how feedback practices interact with cultural contexts is essential for ensuring that all learners are equitably supported in achieving clinical competence. (In this paper we will use “Culture” and derivatives with capitalised “C” to signify the ethnic sense.) Globalisation of health professional education standards can result in the imposition of inappropriate approaches in countries with different cultures and value systems, but without adding value to the education in the recipient countries ( 19 ). The use of assessment and feedback strategies that were developed in Western countries, such as the Mini-Clinical Evaluation Exercise (Mini-CEX), presents potential challenges for educators in the cultures in this review. However, an understanding of these challenges, along with an understanding of the principles of the assessment tools can potentially result in more authentic assessment. The influence of neocolonialism in medical education is a growing concern, particularly in relation to how educational practices align – or fail to align – with local cultural contexts. While decolonisation of medical education has received attention ( 20 – 22 ), questions remain about the appropriateness and effectiveness of certain pedagogical norms that may be imported from Western traditions without sufficient adaptation, or appropriateness of some of the imported practices to Asian contexts. Our interest in the role of culture and learning emerged from observations and conversations with colleagues, some of whom characterised practices such as public humiliation as culturally normative — suggesting that “this is how we Asians learn”. However, such characterisations appear at odds with the perspectives of trainees. This raises critical questions about the appropriateness and effectiveness of such practices in contemporary clinical education. Trainees do request feedback, although it seems that their understanding of the nature of feedback does vary. If feedback is to be upheld as a key element of learning in clinical environments, it is important to ask: which aspects of Culture support the seeking, receiving, and importantly the use of feedback—and which may hinder these processes? So, should we account for local Cultural norms in the context of globalisation of medical education, and if so, how? The countries of Asia and the Middle East are identified as high power distance countries in the Hofstede classification ( 23 ), and most have had a history of colonisation. In places where a wide power distance exists, does the power distance in itself lead to difficulties in provision of feedback, or has it resulted from colonial history? Are the arrogant teachers emulating their teachers from the colonial era, or perhaps their experiences as “International trainees” in universities and teaching hospitals of the former colonial powers? Within Medicine there is a widespread belief that humiliation will motivate trainees to learn ( 24 , 25 ), and a need for “tough love”. Following reports of junior doctor suicides in Malaysia ( 26 – 29 ) we have read social media comments, and heard from senior clinicians, suggestions that Medicine is difficult environment and that trainees need to be “disciplined” so they can cope with the workload – suicide was an indication that the person was not suitable for a career in Medicine. Bullying and humiliation of medical trainees is a worldwide issue with reports for example, from Japan ( 30 ), Pakistan ( 31 ), India and UK ( 32 ), New Zealand ( 33 ), Australia ( 34 ) and US ( 35 ). There is a suggestion that humiliation in medical education is “transgenerational” in a sense similar to observations in the epidemiology of child abuse ( 33 ). With some exceptions ( 36 – 38 ), preliminary searches suggested discussion of feedback in clinical training within Asian contexts is limited, highlighting the need for a systematic mapping of the literature in this area. These early impressions, along with ongoing discussions within the research team, contributed to the refinement of the review question and its scope. A scoping review was the chosen approach to explore an overview of health profession trainees in clinical settings, of how their Asian Cultural background impacts their seeking, receiving and using feedback for learning, with a view to informing constructive approaches in feedback dialogue in the region. Methods We followed the five steps for conducting a Scoping Review ( 39 , 40 ) as discussed below. Step 1: Identify the Research Question This scoping review asks if (and how) trainees in health professions in non-Western settings (excluding Sub-Saharan Africa) in their clinical years of undergraduate and early postgraduate studies are influenced by their Culture in seeking and receiving feedback (and their supervisors in providing feedback)? Step 2: Identify Relevant Studies The final literature search was performed in June 2024 using CINAHL, ERIC, MEDLINE and PsychINFO databases. The search was based on the PCC Model with the format: P opulation: Health Professions Trainees, C ontext: Non-Western Culture, C oncept: Feedback ( 41 ). Search terms and selection criteria were developed in discussion with a librarian and the research team (see Table 1 ). Both MeSH (medical subject headings) and free text were employed to ensure sufficiently wide article coverage. Follow-up searches were made in leading health professional education journals and searching indexes of Southeast Asian medical journals, published in English. Due to lack of funding for translation of articles we were only able to examine literature published in English. Citation mining searches (looking for relevant articles cited in the reference lists of included articles) was also carried out. Table 1 Example of Search strategy used in Ovid MEDLINE, and relevant inclusion and exclusion criteria. Population : Trainee Context : Culture Concept : Feedback Definitions applied in this review Clinical health professions trainees include students and early postgraduates in clinical training for their profession - medicine, nursing, pharmacy, allied health, and their teachers / supervisors Culture is defined by Hofstede as: “The collective programming of the mind that distinguishes one group or category of people from another” ( 42 ) (p. 58). ‘Feedback is a process whereby learners obtain information about their work in order to appreciate the similarities and differences between the appropriate standards for any given work, and the qualities of the work itself, in order to generate improved work’ ( 43 ) (p. 6) Subject Headings e.g. MeSH • Students, Health Occupations • Clinical clerkship • Education, medical/… nursing/… pharmacy/ … public health professional • Clinical competence • Faculty • Faculty, dental/… medical/… nursing • Culture • Cross-Cultural Comparison • Cultural diversity • Cultural difference • Formative feedback • Debrief Keywords and phrases Trainee, Student, Learner, Graduate, Intern Supervisor, Teacher, Lecturer, Instructor, Professor, Tutor Culture Cultural difference Cultural diversity Cultural understanding Cross cultural Ethnic Feedback, Feeding back, Feed-back, Fed back Feedforward, Feed forward, Feeding forward Debrief Inclusion Criteria Medicine, Nursing, Allied Health, Public Health, Pharmacy, Psychology Work-integrated learning, Workplace based assessment Health professions students : pre-registration, specialty training, vocational Educators : Health professions Culture in “Ethnic” sense Asia (South East, South, East, etc), Middle East Verbal, non-verbal, written, Peer, Supervisor, Tutor, Interprofessional, Patient to student Feedback seeking, giving, acceptance, utilisation Exclusion Criteria General tertiary and higher education, Continuing professional development Primary, Secondary School, Pre-University, Special Educ, Learners with a disability, “Train the trainer” Microbiologic, tissue culture, Short international exchanges, Cultural humility, competency Sub-Saharan Africa, Western, Russia, Oceania, Central & South America Physiologic feedback, Feedback on new curriculum, Organisation feedback, Therapeutic feedback, Technology – computer-assisted learning, Patient satisfaction (generic) Step 3: Select studies to be included 1241 references resulted from the database search and 51 potential citations through citation searching were imported into Covidence ( 44 ) for screening. Duplicates were removed before screening. Two team members (PDF and MS) reviewed 10% of the retrieved articles to ensure agreement on criteria. The rest of title and abstract screening was carried out by one of the team members (predominantly PDF) with the intention to err on retaining studies for closer evaluation subsequently. Full texts were then screened by two team members, and team discussion was applied to resolve the disagreements. At the end of this stage, 37 citations were included used for analysis (See the PRISMA-ScR flowchart in Fig. 1 ). Step 4: Chart and Extract Data Included articles were transferred into NVivo software ( 45 ) for coding and data extraction. Step 5: Collating and Reporting results Thematic analysis was applied ( 46 ), and themes identified – initially a sample of articles were analysed as a team to develop the coding framework which was refined iteratively. This was applied to all the studies and comparisons were made between the various geographical and cultural areas. Codes and categories were discussed regularly in team meetings to compare interpretations, negotiate meanings, and discuss our findings within the context of literature. This collaborative process contributed to enhancing the credibility of the analysis and strengthening the overall rigour of the review. Results Study demographics Of the 37 articles reviewed 19 were from South East Asia (dominantly Indonesia 11), six from East Asia, five from South Asia, and seven from the Middle East. Twelve of the articles were published prior to 2020, and 25 were published between 2020 and 2024. Ten articles reported on the views of both trainees and supervisors, 24 reported on trainees only, while three reported on supervisors only. Six studies used Mixed Methods, 19 were Qualitative, while 12 were Quantitative. The dominant feedback type was Negative in 19 articles, Constructive in 2, Neither in 11 and Both in 5. See supplementary Table 1 . Themes Identified Three interconnected themes were identified, mapping the impact of Culture on trainees seeking, receiving and using feedback and supervisors providing that feedback s (see Figure 2): 1. Impact of Culture : Interactions occur between Culture (in the ethnic sense) and culture of the medical system and the learning system. Power distance and, to a lesser extent, collectivism were the main aspects of Culture that influenced perceptions of feedback by both trainees and supervisors while uncertainty avoidance also influenced trainees’ engagement. 2. Diverse perspectives and preferences about the place of feedback: Differing trainee perspectives of the purpose of feedback for developing skills compared with defining correct-incorrect answers was noted. The acceptance of group versus individual feedback appeared to be a significant difference from the existing literature, focused on Western experience, as well as an obvious difference in attitudes to seeking feedback. 3. Feedback seen as error identification, influenced by hierarchy and workload: Supervisors saw their responsibilities in feedback as identifying errors. This was influenced by power distance, their sense of authority, and by service commitments. Impact of Culture Asian Cultures are generally characterised by high power distance and collectivism (48-55) which significantly influence feedback processes. “Face” and “loss of face” as concepts are not uniquely Asian but are stereotypes of Asian Cultures (56) especially in Confucian Heritage Culture. Face is particularly evident in collectivist societies, such as seen in South East and East Asia (36, 38). The Confucian Heritage Culture influence is evident in East and South East Asia and while power distance, collectivism and Face are seen, a bond between trainee and teacher is also recognised (57, 58). A reciprocal relationship between supervisors and trainees is emphasised – seniors are respected, and juniors are nurtured. In Sri Lanka (52, 53) and Thailand (48) this bond between trainee and supervisor was less evident. Thai culture adds “kreng jai” (consideration, deference, and avoiding imposing on others) (48, 59) to strict hierarchy and collectivism and this emphasises avoiding confrontation and not imposing on others (48). Feedback is seen as crucial to learning, but Asian Cultural values shape its reception and use. Teacher-learner feedback sits within two cultures: learning culture and societal culture (48). Both these cultures influence how trainees view and use feedback. Trainees often viewed feedback as a “gift for learning” (60), even when it was harsh and humiliating. Trainees recognised their supervisors’ knowledge and experience, feeling it was an honour to be taught by them (50), but learning was teacher-centric and neglected trainee development (61). Trainees often did not recognise that discussing or questioning feedback was relevant to their learning (51). Clearly feedback models may not translate well between Cultures (38). Cultural differences need recognition when new processes from other cultures are introduced (62) and when meeting “global standards” (36). A conducive training environment is essential for effective feedback. If the environment was perceived unsafe, and negative feedback and punishment occur, “feedback phobia” was reported to result in a lack of engagement and avoidance of learning opportunities (52). Conversely, when trainees felt safe in their learning environment, they were likely to discuss feedback and plans for further development (50). In healthcare settings that were characterised by competing demands and healthcare priorities, trainees acknowledged the heavy workload of their supervisors and were reluctant to request feedback, thus clinical responsibilities over-shadowed teaching and learning (58, 63, 64). Delayed feedback (due to workload) resulted in concerns that feedback given was not specific to their performance (60, 63). Power Distance In high power distance countries relationships in education often parallel those seen in the clinical environment. The Doctor-Patient relationship is paternalistic, and teachers expect to nurture trainees in a similarly paternalistic fashion (54) – ”A teacher for a day, is a father for a lifetime.” (57) (p. 627). In high power distance Cultures children and students are expected to be obedient and submit to their parents or teachers without discussion (65) resulting in a reluctance to question or seek clarification about feedback given (48-50, 54). With a high power distance gap, communication tends to be one-way (61, 63) whereby supervisors identify problems and errors, but do not see the need to provide suggestions for improvement (52). Collectivism and Face Collectivism relates to how individuals integrate into groups and feel an obligation to and dependence on group cohesion (62). In this context trainees tended to be more comfortable to discuss contentious or challenging issues in groups, rather than individually (65). Group feedback was perceived to be provided more frequently than individual feedback, and more appreciated by trainees, especially when provided by specialists (55). The workplace can be considered as a group, and supervisors usually watch individuals as part of the group. Trainees thus are afraid of failing and losing face (38), while they also wish to avoid making mistakes in front of their peers both to maintain group harmony (55) and to avoid humiliation, guilt and loss of face (61). It is noteworthy that group feedback was felt to be more valued and effective in providing goals for the group to work towards, as in a collectivist Culture personal goals are regulated in order to meet group goals (55). Uncertainty Avoidance The influence of a culture of uncertainty avoidance on trainees was evident in their discomfort with contradictory approaches, for example, in performing procedures (63), and a preference for learning from an expert over peer learning as they felt uncertain about the accuracy of information from peers (61). A Singapore study of the Mini-CEX in workplace assessment highlighted that students regarded inter-tutor variability as their most worrying concern in assessment and feedback (66). Two further reports from Singapore found that concerns about trustworthiness of peer feedback persisted (67), despite findings that peer tutors provided accurate, quality feedback (68). Diverse perspectives and preferences about the place of feedback: Trainees in this review valued feedback for learning while their understanding of what constituted feedback varied across countries, and the concept of feedback as dialogue was not widely recognised by trainees (or supervisors). Feedback was more frequently unidirectional than a dialogue, influenced by Cultural factors like power distance (48, 53, 61). Dialogue was limited by trainees’ fear of exposing their weaknesses (49) and even when participating in feedback dialogue, a focus on errors resulted in subordinate roles for trainees (54). Trainees viewed supervisors as unchallengeable experts – from Malaysia (49), to Indonesia (50, 61, 65), Thailand (48), Sri Lanka (52, 53), to UAE (69) – inhibiting questioning of feedback given (50). Perceived harsh feedback was common and frequently judged unhelpful and demotivating (70), or even deceiving (71). However, harsh feedback was valued when it included improvement suggestions (48) and was then seen as a tool for learning (58, 72). Resulting from the combination of power distance and collectivism (together with clinical workload in many sites) was a tendency for feedback to be provided to trainees in groups rather than individually, and in public. In this context group feedback had benefits such as providing feedback to several trainees at once, especially if several trainees had similar difficulties, and was more likely to compare performance with standards (55). It was viewed by trainees as embarrassing when specific individuals were singled out, with humiliation or loss of face (50, 52, 70), as lacking specificity and advice for further development (52, 53) or conversely as a means for the group to identify learning goals (53, 55). Cultural factors influenced responses to negative feedback – although receiving negative feedback is never easy, it was more difficult in a face-saving culture (56, 60). In high power distance and collectivist cultures, feedback aimed to correct errors or behaviours, while identifying good performance was seen as an act of kindness rather than for the benefit of learning (37). This perspective of feedback linked to the belief that punishment was more effective (53), but often resulted in eroded confidence and self-doubt among trainees (53). Trainees described negative feedback as “hostile” or “tense” – one described presenting a case and being accused of cheating, when a correct diagnosis was not reached (52). Trainees often felt feedback was only given by embarrassment and yelling … often in front of peers, the patient or the patient’s family (63, 64, 71). Feedback Seeking Behaviour Barriers to seeking feedback included Cultural norms like power distance and “kreng jai” as well as a lack of feedback seeking ethos. Seeking feedback was considered an imposition on their teachers (48, 49, 53). Where scolding had occurred, or feedback was viewed as superficial or inauthentic, trainees or trainees were less likely to seek feedback (48, 53, 60, 73). Hierarchical structures discouraged trainees from approaching tutors for feedback, especially when they rarely saw junior doctors seeking feedback (53). In the absence of a feedback-seeking educational culture trainees were unsure of what to expect or how to use feedback and needed guidance (64). Emotions, especially fear and embarrassment, hindered feedback seeking and acceptance (54, 61), and even reading written feedback provoked negative reactions (60). When lacking confidence in their progress trainees aimed to avoid embarrassment (51). These negative emotions and perceived lack of trust made trainees feel incompetent in learning to provide clinical care (52, 63). Positive feedback was often seen as mere “praise” and therefore frequently considered valueless by both trainees and supervisors. Trainees questioned the sincerity of what was perceived as “praise” (50), while mentioning what had been done well did not improve Indonesian trainees’ perceptions of feedback received (37). Feedback seen as error identification, influenced by hierarchy and workload: Supervisor feedback concepts appeared to be influenced by Culture, their own experiences as trainees (52, 58), their sense of authority (48, 54, 61, 64), and sometimes generation (50). Provision of feedback was significantly affected by service commitments and prioritising clinical care over teaching and learning (50, 58, 64, 70, 74). Some supervisors felt the need to assert their authority, to be strict and even resort to threats in order to ensure effective learning (54). Supervisors felt trainees wanted "sugar-coated" feedback over what they considered was learning oriented (75) and saw little value in acknowledging what was done well (53). While teachers believed negative feedback was preferable, many acknowledged the need to reinforce good practice so it would continue (48). Balancing positive and negative feedback was noted to be challenging (76). Feedback was commonly expected to be only initiated by the supervisors, solely for identifying and correcting errors (48), and that reinforcing desirable performance was not appropriate (48, 52). In some Sri Lankan hospitals providing feedback was not a formal teaching requirement (53), although most supervisors were committed to their learners (50). Clinical teachers generally felt a sense of responsibility to their juniors, recognised the importance of providing feedback and were committed to a tradition of passing on their expertise to the next generation (57). This aligned with Chinese Cultural values that underscored the bond between teacher and pupil (58). Some authors noted that teachers did not understand how to give constructive feedback (61). This view resonated with the perceptions of fewer than one in three Iranian trainees that their faculty had sufficient skills to provide feedback (64). Faculty development was therefore needed to nurture and improve feedback structures and culture (76, 77). Discussion Although there were variations between countries in Asia and the Middle East and in clinical situations, we found differences in the conceptualisation of feedback between non-Western countries and what is written in generic literature (primarily ‘Western” in origin). A wide power distance influences supervisor-trainee relationships, recognising their upbringing taught respect for their teachers and to maintain a respectful distance. Prevailing power distance and the collectivist perspective influence feedback dynamics. Saving and protecting face, and avoiding uncertainty were also evident. Trainees generally desired feedback, but their understanding of the nature of feedback varied. Aspects of Culture potentially interferes with trainees’ desire to seek feedback. Power distance impacted trainees and supervisors – trainees respected their supervisors as experts ( 50 ), thus felt unable to challenge or seek clarification. Some supervisors actively discouraged questioning and scolded trainees who asked for clarification. Indeed, in some places, even registrars were reluctant to seek feedback. By asking for feedback or asking questions, trainees felt they were exposing deficiencies in knowledge or understanding and feared a loss of face. We acknowledge that wide power distance and collectivist perspectives may negatively influence feedback provision and use, but in doing so we can ask how feedback processes could be modified to meet learning needs of trainees? As an example, with the introduction of the Mini-CEX (Mini-Clinical Evaluation Exercise) at Universitas Gadjah Mada, Indonesia, aspects of local culture were used to enhance the provision and acceptance of feedback for their trainees, in a high power distance, high collectivist environment ( 62 , 78 ). Preferences for feedback varied between unidirectional or dialogue, but even when feedback dialogue was preferred it frequently was unidirectional. Supervisors were caught between service commitments and clinical teaching, with time pressures and a lack of space to use when teaching. A wish to provide the “perfect” approach resulted in one-way feedback to save time. Often, providing feedback to trainees was not regarded as a formal requirement of the curriculum or their teaching responsibilities ( 50 , 53 , 61 , 64 , 73 ) serving as another barrier to providing feedback, let alone feedback dialogue. Group feedback was common due to the combination of Cultural factors and service demands. Group feedback helped specialists to maintain and reinforce system hierarchy, while trainees appreciated group feedback unless it was very personal, in which case it would cause embarrassment to both the trainee in question, and peers. The collectivist approach led trainees to discuss feedback later and was useful in developing collective goals ( 55 , 79 ). In light of current recognition of the importance of interprofessional collaboration in healthcare it would seem a benefit to develop group goal setting and potentially encourage interprofessional teamwork after graduation. In many senses, feedback was understood as telling the trainee what had been done wrong and having identified problems and errors supervisors saw feedback as complete, without the need to provide pointers to improve ( 52 ). In several countries positive feedback was seen by supervisors as mere praise and therefore of limited value ( 48 ) and mentioning strengths was seen being kind ( 37 ). Trainees tended to doubt the sincerity of praise alone ( 50 ) but conversely were willing to accept harsh feedback if it included advice for improvement and felt uncertain without acknowledgement of what had been done well ( 48 , 58 ). This aligns with Hattie and Timperley’s ( 17 ) recognition that feedback about “Self” (as a person) had little value in enhancing learning unless linked to processes or performance. Most countries in this study have been impacted by a historical Confucian influence ( 80 , 81 ). ‘Confucian Heritage Culture’ teaching is often stereotyped as having authoritarian teachers and obedient trainees who rote-learn ( 82 , 83 ). However, Confucian learning does value individuality, reflection and thinking as part of the learning process ( 80 , 83 ). Questioning is accepted, but only after thoughtful reflection which may require some time rather than questioning as an instant response. Clinical supervisors generally felt a responsibility to their trainees with a commitment to a tradition of passing expertise to the next generation, but felt feedback should be initiated by the supervisor, not sought by the trainee ( 48 ). Scolding or punishment were viewed as an important component of providing feedback but potentially created “feedback phobia” resulting in an unwillingness to pursue feedback and demotivating trainees. As a result, they felt they were not trusted by their teachers, were incompetent in providing clinical care, thus reluctant to be involved with patients and impeding learning in the clinical environment. It is worth questioning whether harsh feedback practices stem from Culture, or the supervisors’ own training experiences. We frequently teach the way we were taught. Humiliating, negative feedback can lead to a fixed mindset, hindering learning and development ( 84 – 86 ). Mindset refers to whether people see their abilities as fixed (‘Fixed Mindset’) or can be improved (‘Growth Mindset’). A person’s mindset is not permanent and can be modified ( 84 ). Trainees with a fixed mindset are grade-oriented and expect feedback to provide “correct” answers ( 73 ) – poor performance is attributed to a fixed ability rather than being improvable ( 49 ). Feedback content and delivery shape the trainee’s mindset, so the supervisor can help the trainee develop their self-concept from poor ability to capability ( 49 ). Harsh feedback can result in negative feelings and a superficial approach to learning which reinforces the fixed mindset ( 71 ). Reports of specific Cultural effects on mindset are inconsistent and were not clearly identified in the included studies. However, a United Kingdom study involving local and international veterinary trainees examined mindset related to different curricular areas and found that Cultural background did not affect learning mindset in any areas of that curriculum ( 87 ). Attitudes to formal peer-to-peer feedback were ambivalent – valued by some, distrusted by others, although this was discussed in a small number of the included studies. Structured peer-to-peer feedback for practical skills was beneficial and encouraged reflection on the skills assessed. Some trainees were concerned that peer feedback might lead them astray ( 67 ), while in other circumstances, peer feedback was the most common feedback source ( 64 ). This scoping review found little to contradict the importance of feedback for health profession trainees’ clinical learning in non-Western settings, but Culture did affect feedback delivery by many supervisors, and trainees commonly were reluctant to seek feedback themselves. The experience at Universitas Gadjah Mada in Indonesia with the introduction of the Mini-Clinical Evaluation Exercise (Mini-CEX, an imported assessment tool) showed that contextualising this assessment to the local Culture enhanced feedback provision in a culturally appropriate manner ( 36 , 78 ). Humiliating feedback did not enhance trainees’ learning, contrary to the belief that it was necessary for trainees to learn, and to prepare them for the stresses of clinical practice. In a Western discussion of emotions and feedback provision, Ilgen and Davis ( 88 ) highlighted that negative feedback given without providing strategies for improvement resulted in learned helplessness. Asian trainees reported demotivation after scolding ( 52 ), disregarded harsh feedback ( 53 ) and defined feedback as positive if it provided a path to improvement even when provided in a harsh manner ( 48 ). Unconstructive feedback made trainees feel incompetent to participate in patient care and they avoided opportunities to learn ( 63 ). Western discussion of feedback (particularly over the past ten years or so) emphasises a need for dialogue and the trainee’s active role in seeking, reflecting on, and using feedback. Trainees need opportunities to apply feedback in practice and to develop self-assessment skills ( 89 ). The studies reviewed provided little evidence to contradict these key aspects of feedback, but feedback approaches need to be contextualised to local Culture and healthcare services. We suggest that Western clinical teaching could benefit by adapting group feedback practices to enhance learning. Implications for further research From this scoping review we note that Culture, particularly power distance and collectivism, has an important impact on both trainee and supervisor conceptions about the place of feedback on learning in the clinical environment and results in predominantly “negative” feedback that is often harsh and punitive. Aspects of the healthcare system and education system cultures also influence preconceptions and negative (or absent) feedback. We observed tensions and contradictions in the way that feedback is perceived by trainees and their supervisors across Asia and the Middle East, with differences in approaches from that suggested as ideal in generic (‘Western’) literature. We see the following as having potential to clarify feedback benefits across Cultures. Further research would be useful to identify other approaches to providing feedback in the high power distance, collectivist Cultures, and inform faculty development for clinical teachers. For the trainee who grew up in such Cultures and was schooled in a high power distance society, identifying effective approaches to encouraging feedback seeking, identifying feedback needs and using feedback provided could be valuable. It is also important to consider what pedagogical lessons Western clinical learning could take from Asia. Group feedback in collectivist Cultures provided benefits by generating group performance goals and provided a means to address performance difficulties involving several trainees. In a time-pressured learning environment, group feedback provided potential efficiencies. In the studies reviewed, there was little discussion about how feedback was used. Reflecting on feedback provided did not appear to be considered important. Further research may identify the place for encouraging reflection by trainees in the region, and if so, how should this occur? What is the concept of reflection in non-Western Cultures, and is reflection a key to using feedback in these Cultures? Limitations The most obvious limitation to this review is that it was restricted to articles published in English. Due to our limited language proficiency and the absence of funding for translation, we were unable to include literature published in local languages. Locally published work could offer culturally nuanced insights into the role of feedback in education. The review was started when there were few studies of feedback in the region, but there has been an awakening of interest in this topic in Asia. We are hopeful that this review and our study informed by this review will provide ideas to enhance the provision and use of feedback within the region. Conclusion The importance of feedback is recognised widely and desired by trainees. Clearly there are both similarities and differences in the way feedback is conceived and provided in Western and Asian Cultures. Aspects of Culture do influence the way feedback is given and received. Using the Hofstede typology, high power distance and collectivism appeared to have the most obvious effects by inhibiting trainees from seeking feedback, requesting clarification of feedback given and thus dialogue. Collectivism, along with power distance and the impact of clinical service pressures, resulted in much feedback being given to trainees in groups. In this context group feedback had advantages in that using the feedback given became a group goal. We see this as having the potential to develop skills that would enhance future interprofessional collaboration in the clinical work environment. Abbreviations MeSH Medical Subject Headings Mini-CEX Mini-Clinical Evaluation Exercise Declarations Ethics approval: As this study is a literature review, ethics approval is not required. Consent for publication: Not required Funding: None Author Contribution PDF developed the original idea for this review in collaboration with MS, WM and SH, and later VN and VP. Initial screening of titles and abstracts and then full texts of retrieved articles was performed by PDF and MS, with input from WM and SH. Extraction of data and development of themes were performed by PDF, MS, VN and VP. PDF wrote the original draft of the review, which was subsequently refined by all authors. All authors agree to be accountable for all aspects of this review. PDF is guarantor of the review. Acknowledgements: We would like to acknowledge the contributions of A/Prof Wendy McKenzie (WM) and A/Prof Shamsul Haque (SH) to the earlier development of this review. Clinical trial number: Not applicable. Data Availability Data available from the corresponding author upon request. References Ajjawi R, Regehr G. When I say … feedback. Medical Education. 2019;53(7):652-4 https://doi.org/10.1111/medu.13746. Bearman M, Brown J, Kirby C, Ajjawi R. Feedback That Helps Trainees Learn to Practice Without Supervision. Acad Med. 2020;96(2):205–9. https://doi.org/10.1097/ACM.0000000000003716 . Molloy E, Ajjawi R, Bearman M, Noble C, Rudland J, Ryan A. Challenging feedback myths: Values, learner involvement and promoting effects beyond the immediate task. 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Supplementary Files SupplementaryTable1.docx Cite Share Download PDF Status: Published Journal Publication published 29 Nov, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 20 Aug, 2025 Reviews received at journal 17 Aug, 2025 Reviews received at journal 16 Aug, 2025 Reviews received at journal 11 Aug, 2025 Reviews received at journal 08 Aug, 2025 Reviewers agreed at journal 05 Aug, 2025 Reviewers agreed at journal 04 Aug, 2025 Reviewers agreed at journal 04 Aug, 2025 Reviewers agreed at journal 01 Aug, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers invited by journal 17 Jul, 2025 Editor assigned by journal 16 Jul, 2025 Editor invited by journal 16 Jul, 2025 Submission checks completed at journal 15 Jul, 2025 First submitted to journal 15 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7074261","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":487935681,"identity":"8143cd64-0836-4be5-bd88-b62fa4bf18ee","order_by":0,"name":"Paul Douglas Fullerton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYHACxgMMNgwyfBCODZhkBgk34NFzgCGNgYcNoiiNdC2HCWsxZz9jcIAh4TAPG3vv8wcfd5yP5pdufvy5gMFGdsMB7Fose3KgWniOGzbOPHM7d+acY2bSMxjSjHFpMTgA1ML4A6hFIo2xmbftdu6GGwlmzDwMhxNxajn/BmqL/DOQlnNALemfP/Mw/Met5QbMYRJsIC0HgFpyDKR5GA7g1GI541nBgYSEdKBf0hhnzmxLzp05I6dMmscg2XgmDi3m/MkbH3xIsJbjZz/G8OFjm11uv0T65s88FXayfbgcBiIScIjj0TIKRsEoGAWjAC8AABXlXtZYbwgjAAAAAElFTkSuQmCC","orcid":"","institution":"Monash University Malaysia","correspondingAuthor":true,"prefix":"","firstName":"Paul","middleName":"Douglas","lastName":"Fullerton","suffix":""},{"id":487935682,"identity":"96a0f3f7-086c-4e1e-9201-ad8f6d705be4","order_by":1,"name":"Van Nguyen","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Van","middleName":"","lastName":"Nguyen","suffix":""},{"id":487935683,"identity":"ca6424d2-c2ac-4760-881a-d8bd3669a880","order_by":2,"name":"Vinod Pallath","email":"","orcid":"","institution":"Monash University Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Vinod","middleName":"","lastName":"Pallath","suffix":""},{"id":487935684,"identity":"1e21c594-9085-4300-b5f7-1bc1a4bc34ea","order_by":3,"name":"Mahbub Sarkar","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Mahbub","middleName":"","lastName":"Sarkar","suffix":""}],"badges":[],"createdAt":"2025-07-08 11:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7074261/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7074261/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-08307-z","type":"published","date":"2025-11-29T15:58:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87226636,"identity":"e18593f0-188d-4408-85c8-de8dbec51951","added_by":"auto","created_at":"2025-07-21 17:32:44","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":589146,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA-ScR Flowchart (47)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7074261/v1/cc08100db3b54765c6b8ab47.jpeg"},{"id":87226640,"identity":"cb585d5b-092e-46c3-b2d9-ec4a953b27b5","added_by":"auto","created_at":"2025-07-21 17:32:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":101773,"visible":true,"origin":"","legend":"\u003cp\u003eCulture and Feedback Perspectives\u003c/p\u003e\n\u003cp\u003ePower distance and collectivism were major aspects of Culture that influenced feedback processes in clinical learning, but also impacted upbringing and past (school, especially) experience. Culture impacted trainee and supervisor perceptions, as did healthcare and education culture. Dominant feedback provided was harsh, negative feedback influencing, in turn, trainee perceptions of what was expected of them and their performance. Positive feedback mitigated the effect of the harsh feedback, although harshly toned feedback with advice about changes was often described as positive.\u003c/p\u003e\n\u003cp\u003e· Box and circle sizes attempt to signify the relative importance of factors as judged from the literature reviewed.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7074261/v1/7c313fac153f63a24a8d8bba.png"},{"id":97179383,"identity":"018ce883-9c74-4454-9672-b71ce945c460","added_by":"auto","created_at":"2025-12-01 16:15:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1582933,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7074261/v1/db6ca366-ba40-48ae-8368-0f885abe7bf8.pdf"},{"id":87226635,"identity":"ae092825-9ca9-4d50-bce8-f701a4acad70","added_by":"auto","created_at":"2025-07-21 17:32:44","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":54502,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7074261/v1/0a0dcf872432eee1fd18cff3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cultural influences on non-Western health profession trainees seeking and receiving feedback: A Scoping Review","fulltext":[{"header":"Background","content":"\u003cp\u003eFeedback plays a key role in learning and professional development for health professionals (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Much of the existing literature is grounded in Western educational contexts (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), leaving a gap in our understanding of how feedback is conceptualised, sought, and used in non-Western contexts. This presents a significant gap, particularly in relation to Asian countries, where Cultural values and educational traditions may shape feedback dynamics in ways that differ from Western norms. What constitutes feedback in one Culture may not hold the same meaning in another. This raises important questions: Do Cultural norms shape how trainees seek and interpret feedback? If so, what are the implications for the development of clinical competence in Asian contexts? In an increasingly globalised educational landscape, understanding how feedback practices interact with cultural contexts is essential for ensuring that all learners are equitably supported in achieving clinical competence. (In this paper we will use “Culture” and derivatives with capitalised “C” to signify the ethnic sense.)\u003c/p\u003e\u003cp\u003eGlobalisation of health professional education standards can result in the imposition of inappropriate approaches in countries with different cultures and value systems, but without adding value to the education in the recipient countries (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The use of assessment and feedback strategies that were developed in Western countries, such as the Mini-Clinical Evaluation Exercise (Mini-CEX), presents potential challenges for educators in the cultures in this review. However, an understanding of these challenges, along with an understanding of the principles of the assessment tools can potentially result in more authentic assessment.\u003c/p\u003e\u003cp\u003eThe influence of neocolonialism in medical education is a growing concern, particularly in relation to how educational practices align – or fail to align – with local cultural contexts. While decolonisation of medical education has received attention (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e–\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), questions remain about the appropriateness and effectiveness of certain pedagogical norms that may be imported from Western traditions without sufficient adaptation, or appropriateness of some of the imported practices to Asian contexts. Our interest in the role of culture and learning emerged from observations and conversations with colleagues, some of whom characterised practices such as public humiliation as culturally normative — suggesting that “this is how we Asians learn”. However, such characterisations appear at odds with the perspectives of trainees. This raises critical questions about the appropriateness and effectiveness of such practices in contemporary clinical education. Trainees do request feedback, although it seems that their understanding of the nature of feedback does vary. If feedback is to be upheld as a key element of learning in clinical environments, it is important to ask: which aspects of Culture support the seeking, receiving, and importantly the use of feedback—and which may hinder these processes?\u003c/p\u003e\u003cp\u003eSo, should we account for local Cultural norms in the context of globalisation of medical education, and if so, how? The countries of Asia and the Middle East are identified as high power distance countries in the Hofstede classification (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), and most have had a history of colonisation. In places where a wide power distance exists, does the power distance in itself lead to difficulties in provision of feedback, or has it resulted from colonial history? Are the arrogant teachers emulating their teachers from the colonial era, or perhaps their experiences as “International trainees” in universities and teaching hospitals of the former colonial powers? Within Medicine there is a widespread belief that humiliation will motivate trainees to learn (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), and a need for “tough love”. Following reports of junior doctor suicides in Malaysia (\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e–\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) we have read social media comments, and heard from senior clinicians, suggestions that Medicine is difficult environment and that trainees need to be “disciplined” so they can cope with the workload – suicide was an indication that the person was not suitable for a career in Medicine. Bullying and humiliation of medical trainees is a worldwide issue with reports for example, from Japan (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), Pakistan (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), India and UK (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), New Zealand (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), Australia (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and US (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). There is a suggestion that humiliation in medical education is “transgenerational” in a sense similar to observations in the epidemiology of child abuse (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWith some exceptions (\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e–\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), preliminary searches suggested discussion of feedback in clinical training within Asian contexts is limited, highlighting the need for a systematic mapping of the literature in this area. These early impressions, along with ongoing discussions within the research team, contributed to the refinement of the review question and its scope. A scoping review was the chosen approach to explore an overview of health profession trainees in clinical settings, of how their Asian Cultural background impacts their seeking, receiving and using feedback for learning, with a view to informing constructive approaches in feedback dialogue in the region.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe followed the five steps for conducting a Scoping Review (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) as discussed below.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStep 1: Identify the Research Question\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis scoping review asks if (and how) trainees in health professions in non-Western settings (excluding Sub-Saharan Africa) in their clinical years of undergraduate and early postgraduate studies are influenced by their Culture in seeking and receiving feedback (and their supervisors in providing feedback)?\u003c/p\u003e\u003cp\u003e\u003cem\u003eStep 2: Identify Relevant Studies\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe final literature search was performed in June 2024 using CINAHL, ERIC, MEDLINE and PsychINFO databases. The search was based on the PCC Model with the format: \u003cb\u003eP\u003c/b\u003eopulation: Health Professions Trainees, \u003cb\u003eC\u003c/b\u003eontext: Non-Western Culture, \u003cb\u003eC\u003c/b\u003eoncept: Feedback (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSearch terms and selection criteria were developed in discussion with a librarian and the research team (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Both MeSH (medical subject headings) and free text were employed to ensure sufficiently wide article coverage. Follow-up searches were made in leading health professional education journals and searching indexes of Southeast Asian medical journals, published in English. Due to lack of funding for translation of articles we were only able to examine literature published in English. Citation mining searches (looking for relevant articles cited in the reference lists of included articles) was also carried out.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eExample of Search strategy used in Ovid MEDLINE, and relevant inclusion and exclusion criteria.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePopulation\u003c/span\u003e: Trainee\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eContext\u003c/span\u003e: Culture\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eConcept\u003c/span\u003e: Feedback\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eDefinitions applied in this review\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical health professions trainees include students and early postgraduates in clinical training for their profession - medicine, nursing, pharmacy, allied health, and their teachers / supervisors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCulture is defined by Hofstede as: \u003cem\u003e“The collective programming of the mind that distinguishes one group or category of people from another”\u003c/em\u003e (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) \u003cem\u003e(p. 58).\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e‘Feedback is a process whereby learners obtain information about their work in order to appreciate the similarities and differences between the appropriate standards for any given work, and the qualities of the work itself, in order to generate improved work’\u003c/em\u003e (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) \u003cem\u003e(p. 6)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubject Headings e.g. MeSH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e• Students, Health Occupations\u003c/p\u003e\u003cp\u003e• Clinical clerkship\u003c/p\u003e\u003cp\u003e• Education, medical/… nursing/… pharmacy/ … public health professional\u003c/p\u003e\u003cp\u003e• Clinical competence\u003c/p\u003e\u003cp\u003e• Faculty\u003c/p\u003e\u003cp\u003e• Faculty, dental/… medical/… nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e• Culture\u003c/p\u003e\u003cp\u003e• Cross-Cultural Comparison\u003c/p\u003e\u003cp\u003e• Cultural diversity\u003c/p\u003e\u003cp\u003e• Cultural difference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e• Formative feedback\u003c/p\u003e\u003cp\u003e• Debrief\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKeywords and phrases\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrainee, Student, Learner, Graduate, Intern\u003c/p\u003e\u003cp\u003eSupervisor, Teacher, Lecturer, Instructor, Professor, Tutor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCulture\u003c/p\u003e\u003cp\u003eCultural difference\u003c/p\u003e\u003cp\u003eCultural diversity\u003c/p\u003e\u003cp\u003eCultural understanding\u003c/p\u003e\u003cp\u003eCross cultural\u003c/p\u003e\u003cp\u003eEthnic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFeedback, Feeding back, Feed-back, Fed back\u003c/p\u003e\u003cp\u003eFeedforward, Feed forward,\u003c/p\u003e\u003cp\u003eFeeding forward\u003c/p\u003e\u003cp\u003eDebrief\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedicine, Nursing, Allied Health, Public Health, Pharmacy, Psychology\u003c/p\u003e\u003cp\u003eWork-integrated learning, Workplace based assessment\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHealth professions students\u003c/span\u003e:\u003c/p\u003e\u003cp\u003epre-registration, specialty training, vocational\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEducators\u003c/span\u003e: Health professions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCulture in “Ethnic” sense\u003c/p\u003e\u003cp\u003eAsia (South East, South, East, etc), Middle East\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVerbal, non-verbal, written,\u003c/p\u003e\u003cp\u003ePeer, Supervisor, Tutor, Interprofessional,\u003c/p\u003e\u003cp\u003ePatient to student\u003c/p\u003e\u003cp\u003eFeedback seeking, giving, acceptance, utilisation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneral tertiary and higher education, Continuing professional development\u003c/p\u003e\u003cp\u003ePrimary, Secondary School, Pre-University, Special Educ,\u003c/p\u003e\u003cp\u003eLearners with a disability,\u003c/p\u003e\u003cp\u003e“Train the trainer”\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMicrobiologic, tissue culture,\u003c/p\u003e\u003cp\u003eShort international exchanges,\u003c/p\u003e\u003cp\u003eCultural humility, competency\u003c/p\u003e\u003cp\u003eSub-Saharan Africa,\u003c/p\u003e\u003cp\u003eWestern, Russia, Oceania,\u003c/p\u003e\u003cp\u003eCentral \u0026amp; South America\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysiologic feedback, Feedback on new curriculum, Organisation feedback, Therapeutic feedback,\u003c/p\u003e\u003cp\u003eTechnology – computer-assisted learning, Patient satisfaction (generic)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStep 3: Select studies to be included\u003c/em\u003e\u003c/p\u003e\u003cp\u003e1241 references resulted from the database search and 51 potential citations through citation searching were imported into Covidence (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) for screening. Duplicates were removed before screening. Two team members (PDF and MS) reviewed 10% of the retrieved articles to ensure agreement on criteria. The rest of title and abstract screening was carried out by one of the team members (predominantly PDF) with the intention to err on retaining studies for closer evaluation subsequently.\u003c/p\u003e\u003cp\u003eFull texts were then screened by two team members, and team discussion was applied to resolve the disagreements. At the end of this stage, 37 citations were included used for analysis (See the PRISMA-ScR flowchart in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cem\u003eStep 4: Chart and Extract Data\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIncluded articles were transferred into NVivo software (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) for coding and data extraction.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStep 5: Collating and Reporting results\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThematic analysis was applied (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), and themes identified – initially a sample of articles were analysed as a team to develop the coding framework which was refined iteratively. This was applied to all the studies and comparisons were made between the various geographical and cultural areas. Codes and categories were discussed regularly in team meetings to compare interpretations, negotiate meanings, and discuss our findings within the context of literature. This collaborative process contributed to enhancing the credibility of the analysis and strengthening the overall rigour of the review.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eStudy demographics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 37 articles reviewed 19 were from South East Asia (dominantly Indonesia 11), six from East Asia, five from South Asia, and seven from the Middle East. \u0026nbsp;Twelve of the articles were published prior to 2020, and 25 were published between 2020 and 2024. \u0026nbsp;Ten articles reported on the views of both trainees and supervisors, 24 reported on trainees only, while three reported on supervisors only. \u0026nbsp;Six studies used Mixed Methods, 19 were Qualitative, while 12 were Quantitative. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe dominant feedback type was Negative in 19 articles, Constructive in 2, Neither in 11 and Both in 5. \u0026nbsp;\u003cem\u003eSee supplementary Table 1\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThemes Identified\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree interconnected themes were identified, mapping the impact of Culture on trainees seeking, receiving and using feedback and supervisors providing that feedback s (see Figure 2):\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1. \u003cstrong\u003eImpact of Culture\u003c/strong\u003e: \u0026nbsp;Interactions occur between Culture (in the ethnic sense) and culture of the medical system and the learning system. \u0026nbsp;Power distance and, to a lesser extent, collectivism were the main aspects of Culture that influenced perceptions of feedback by both trainees and supervisors while uncertainty avoidance also influenced trainees\u0026rsquo; engagement.\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003eDiverse perspectives and preferences about the place of feedback: \u0026nbsp;\u003c/strong\u003eDiffering trainee perspectives of the purpose of feedback for developing skills compared with defining correct-incorrect answers was noted. \u0026nbsp;The acceptance of group versus individual feedback appeared to be a significant difference from the existing literature, focused on Western experience, as well as an obvious difference in attitudes to seeking feedback. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. \u003cstrong\u003eFeedback seen as error identification, influenced by hierarchy and workload:\u003c/strong\u003e\u0026nbsp; Supervisors saw their responsibilities in feedback as identifying errors. \u0026nbsp;This was influenced by power distance, their sense of authority, and by service commitments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImpact of Culture\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAsian Cultures are generally characterised by high power distance and collectivism (48-55) which significantly influence feedback processes. \u0026nbsp; \u0026ldquo;Face\u0026rdquo; and \u0026ldquo;loss of face\u0026rdquo; as concepts are not uniquely Asian but are stereotypes of Asian Cultures (56) especially in Confucian Heritage Culture. \u0026nbsp;Face is particularly evident in collectivist societies, such as seen in South East and East Asia (36, 38). The Confucian Heritage Culture influence is evident in East and South East Asia and while power distance, collectivism and Face are seen, a bond between trainee and teacher is also recognised (57, 58). \u0026nbsp;A reciprocal relationship between supervisors and trainees is emphasised \u0026ndash; seniors are respected, and juniors are nurtured. \u0026nbsp;In Sri Lanka (52, 53) and Thailand (48) this bond between trainee and supervisor was less evident. \u0026nbsp;Thai culture adds \u0026ldquo;kreng jai\u0026rdquo; (consideration, deference, and avoiding imposing on others) (48, 59) to strict hierarchy and collectivism and this emphasises avoiding confrontation and not imposing on others (48).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFeedback is seen as crucial to learning, but Asian Cultural values shape its reception and use. Teacher-learner feedback sits within two cultures: \u0026nbsp;learning culture and societal culture (48). \u0026nbsp;Both these cultures influence how trainees view and use feedback. \u0026nbsp;Trainees often viewed feedback as a \u0026ldquo;gift for learning\u0026rdquo; (60), even when it was harsh and humiliating. \u0026nbsp; Trainees recognised their supervisors\u0026rsquo; knowledge and experience, feeling it was an honour to be taught by them (50), but learning was teacher-centric and neglected trainee development (61). \u0026nbsp;Trainees often did not recognise that discussing or questioning feedback was relevant to their learning (51). \u0026nbsp;Clearly feedback models may not translate well between Cultures (38). \u0026nbsp;Cultural differences need recognition when new processes from other cultures are introduced (62) and when meeting \u0026ldquo;global standards\u0026rdquo; (36).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA conducive training environment is essential for effective feedback. \u0026nbsp;If the environment was perceived unsafe, and negative feedback and punishment occur, \u0026ldquo;feedback phobia\u0026rdquo; was reported to result in a lack of engagement and avoidance of learning opportunities (52). \u0026nbsp;Conversely, when trainees felt safe in their learning environment, they were likely to discuss feedback and plans for further development (50). \u0026nbsp;In healthcare settings that were characterised by competing demands and healthcare priorities, trainees acknowledged the heavy workload of their supervisors and were reluctant to request feedback, thus clinical responsibilities over-shadowed teaching and learning (58, 63, 64). \u0026nbsp;Delayed feedback (due to workload) resulted in concerns that feedback given was not specific to their performance (60, 63).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePower Distance\u003c/p\u003e\n\u003cp\u003eIn high power distance countries relationships in education often parallel those seen in the clinical environment. The Doctor-Patient relationship is paternalistic, and teachers expect to nurture trainees in a similarly paternalistic fashion (54) \u0026ndash; \u003cem\u003e\u0026rdquo;A teacher for a day, is a father for a lifetime.\u0026rdquo;\u003c/em\u003e\u0026nbsp; (57) (p. 627). \u0026nbsp;In high power distance Cultures children and students are expected to be obedient and submit to their parents or teachers without discussion (65) resulting in a reluctance to question or seek clarification about feedback given (48-50, 54). With a high power distance gap, communication tends to be one-way (61, 63) whereby supervisors identify problems and errors, but do not see the need to provide suggestions for improvement (52).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCollectivism and Face\u003c/p\u003e\n\u003cp\u003eCollectivism relates to how individuals integrate into groups and feel an obligation to and dependence on group cohesion (62). \u0026nbsp;In this context trainees tended to be more comfortable to discuss contentious or challenging issues in groups, rather than individually (65). \u0026nbsp;Group feedback was perceived to be provided more frequently than individual feedback, and more appreciated by trainees, especially when provided by specialists (55). \u0026nbsp;The workplace can be considered as a group, and supervisors usually watch individuals as part of the group. \u0026nbsp; Trainees thus are afraid of failing and losing face (38), while they also wish to avoid making mistakes in front of their peers both to maintain group harmony (55) and to avoid humiliation, guilt and loss of face (61). \u0026nbsp;It is noteworthy that group feedback was felt to be more valued and effective in providing goals for the group to work towards, as in a collectivist Culture personal goals are regulated in order to meet group goals (55).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUncertainty Avoidance\u003c/p\u003e\n\u003cp\u003eThe influence of a culture of uncertainty avoidance on trainees was evident in their discomfort with contradictory approaches, for example, in performing procedures (63), and a preference for learning from an expert over peer learning as they felt uncertain about the accuracy of information from peers (61). \u0026nbsp;A Singapore study of the Mini-CEX in workplace assessment highlighted that students regarded inter-tutor variability as their most worrying concern in assessment and feedback (66). \u0026nbsp;Two further reports from Singapore found that concerns about trustworthiness of peer feedback persisted (67), despite findings that peer tutors provided accurate, quality feedback (68). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiverse perspectives and preferences about the place of feedback: \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTrainees in this review valued feedback for learning while their understanding of what constituted feedback varied across countries, and the concept of feedback as dialogue was not widely recognised by trainees (or supervisors). \u0026nbsp;Feedback was more frequently unidirectional than a dialogue, influenced by Cultural factors like power distance (48, 53, 61). \u0026nbsp;Dialogue was limited by trainees\u0026rsquo; fear of exposing their weaknesses (49) and even when participating in feedback dialogue, a focus on errors resulted in subordinate roles for trainees (54). Trainees viewed supervisors as unchallengeable experts \u0026ndash; from Malaysia (49), to Indonesia (50, 61, 65), Thailand (48), Sri Lanka (52, 53), to UAE (69) \u0026ndash; inhibiting questioning of feedback given (50). \u0026nbsp;Perceived harsh feedback was common and frequently judged unhelpful and demotivating (70), or even deceiving (71). \u0026nbsp;However, harsh feedback was valued when it included improvement suggestions (48) and was then seen as a tool for learning (58, 72). \u0026nbsp;Resulting from the combination of power distance and collectivism (together with clinical workload in many sites) was a tendency for feedback to be provided to trainees in groups rather than individually, and in public. \u0026nbsp;In this context group feedback had benefits such as providing feedback to several trainees at once, especially if several trainees had similar difficulties, and was more likely to compare performance with standards (55). \u0026nbsp;It was viewed by trainees as embarrassing when specific individuals were singled out, with humiliation or loss of face (50, 52, 70), as lacking specificity and advice for further development (52, 53) or conversely as a means for the group to identify learning goals (53, 55). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCultural factors influenced responses to negative feedback \u0026ndash; although receiving negative feedback is never easy, it was more difficult in a face-saving culture (56, 60). \u0026nbsp;In high power distance and collectivist cultures, feedback aimed to correct errors or behaviours, while identifying good performance was seen as an act of kindness rather than for the benefit of learning (37). \u0026nbsp;This perspective of feedback linked to the belief that punishment was more effective (53), but often resulted in eroded confidence and self-doubt among trainees (53). \u0026nbsp;Trainees described negative feedback as \u0026ldquo;hostile\u0026rdquo; or \u0026ldquo;tense\u0026rdquo; \u0026ndash; one described presenting a case and being accused of cheating, when a correct diagnosis was not reached (52). \u0026nbsp;Trainees often felt feedback was only given by embarrassment and yelling \u0026hellip; often in front of peers, the patient or the patient\u0026rsquo;s family (63, 64, 71).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFeedback Seeking Behaviour\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBarriers to seeking feedback included Cultural norms like power distance and \u0026ldquo;kreng jai\u0026rdquo; as well as a lack of feedback seeking ethos. \u0026nbsp; Seeking feedback was considered an imposition on their teachers (48, 49, 53). \u0026nbsp;Where scolding had occurred, or feedback was viewed as superficial or inauthentic, trainees or trainees were less likely to seek feedback (48, 53, 60, 73). Hierarchical structures discouraged trainees from approaching tutors for feedback, especially when they rarely saw junior doctors seeking feedback (53). \u0026nbsp;In the absence of a feedback-seeking educational culture trainees were unsure of what to expect or how to use feedback and needed guidance (64).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmotions, especially fear and embarrassment, hindered feedback seeking and acceptance (54, 61), and even reading written feedback provoked negative reactions (60). \u0026nbsp;When lacking confidence in their progress trainees aimed to avoid embarrassment (51). \u0026nbsp;These negative emotions and perceived lack of trust made trainees feel incompetent in learning to provide clinical care (52, 63). \u0026nbsp;Positive feedback was often seen as mere \u0026ldquo;praise\u0026rdquo; and therefore frequently considered valueless by both trainees and supervisors. \u0026nbsp;Trainees questioned the sincerity of what was perceived as \u0026ldquo;praise\u0026rdquo; (50), while mentioning what had been done well did not improve Indonesian trainees\u0026rsquo; perceptions of feedback received (37).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFeedback seen as error identification, influenced by hierarchy and workload:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupervisor feedback concepts appeared to be influenced by Culture, their own experiences as trainees (52, 58), their sense of authority (48, 54, 61, 64), and sometimes generation (50). \u0026nbsp;Provision of feedback was significantly affected by service commitments and prioritising clinical care over teaching and learning (50, 58, 64, 70, 74). \u0026nbsp;Some supervisors felt the need to assert their authority, to be strict and even resort to threats in order to ensure effective learning (54). \u0026nbsp;Supervisors felt trainees wanted \u0026quot;sugar-coated\u0026quot; feedback over what they considered was learning oriented (75) and saw little value in acknowledging what was done well (53). \u0026nbsp;While teachers believed negative feedback was preferable, many acknowledged the need to reinforce good practice so it would continue (48). \u0026nbsp;Balancing positive and negative feedback was noted to be challenging (76).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFeedback was commonly expected to be only initiated by the supervisors, solely for identifying and correcting errors (48), and that reinforcing desirable performance was not appropriate (48, 52). \u0026nbsp;In some Sri Lankan hospitals providing feedback was not a formal teaching requirement (53), although most supervisors were committed to their learners (50). \u0026nbsp;Clinical teachers generally felt a sense of responsibility to their juniors, recognised the importance of providing feedback and were committed to a tradition of passing on their expertise to the next generation (57). \u0026nbsp;This aligned with Chinese Cultural values that underscored the bond between teacher and pupil (58). \u0026nbsp;Some authors noted that teachers did not understand how to give constructive feedback (61). \u0026nbsp;This view resonated with the perceptions of fewer than one in three Iranian trainees that their faculty had sufficient skills to provide feedback (64). \u0026nbsp;Faculty development was therefore needed to nurture and improve feedback structures and culture (76, 77).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough there were variations between countries in Asia and the Middle East and in clinical situations, we found differences in the conceptualisation of feedback between non-Western countries and what is written in generic literature (primarily \u0026lsquo;Western\u0026rdquo; in origin). A wide power distance influences supervisor-trainee relationships, recognising their upbringing taught respect for their teachers and to maintain a respectful distance. Prevailing power distance and the collectivist perspective influence feedback dynamics. Saving and protecting face, and avoiding uncertainty were also evident.\u003c/p\u003e\u003cp\u003eTrainees generally desired feedback, but their understanding of the nature of feedback varied. Aspects of Culture potentially interferes with trainees\u0026rsquo; desire to seek feedback. Power distance impacted trainees and supervisors \u0026ndash; trainees respected their supervisors as experts (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), thus felt unable to challenge or seek clarification. Some supervisors actively discouraged questioning and scolded trainees who asked for clarification. Indeed, in some places, even registrars were reluctant to seek feedback. By asking for feedback or asking questions, trainees felt they were exposing deficiencies in knowledge or understanding and feared a loss of face.\u003c/p\u003e\u003cp\u003eWe acknowledge that wide power distance and collectivist perspectives may negatively influence feedback provision and use, but in doing so we can ask how feedback processes could be modified to meet learning needs of trainees? As an example, with the introduction of the Mini-CEX (Mini-Clinical Evaluation Exercise) at Universitas Gadjah Mada, Indonesia, aspects of local culture were used to enhance the provision and acceptance of feedback for their trainees, in a high power distance, high collectivist environment (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePreferences for feedback varied between unidirectional or dialogue, but even when feedback dialogue was preferred it frequently was unidirectional. Supervisors were caught between service commitments and clinical teaching, with time pressures and a lack of space to use when teaching. A wish to provide the \u0026ldquo;perfect\u0026rdquo; approach resulted in one-way feedback to save time. Often, providing feedback to trainees was not regarded as a formal requirement of the curriculum or their teaching responsibilities (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e) serving as another barrier to providing feedback, let alone feedback dialogue.\u003c/p\u003e\u003cp\u003eGroup feedback was common due to the combination of Cultural factors and service demands. Group feedback helped specialists to maintain and reinforce system hierarchy, while trainees appreciated group feedback unless it was very personal, in which case it would cause embarrassment to both the trainee in question, and peers. The collectivist approach led trainees to discuss feedback later and was useful in developing collective goals (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e). In light of current recognition of the importance of interprofessional collaboration in healthcare it would seem a benefit to develop group goal setting and potentially encourage interprofessional teamwork after graduation.\u003c/p\u003e\u003cp\u003eIn many senses, feedback was understood as \u003cem\u003etelling\u003c/em\u003e the trainee what had been done wrong and having identified problems and errors supervisors saw feedback as complete, without the need to provide pointers to improve (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). In several countries positive feedback was seen by supervisors as mere praise and therefore of limited value (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) and mentioning strengths was seen being kind (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Trainees tended to doubt the sincerity of praise alone (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) but conversely were willing to accept harsh feedback if it included advice for improvement and felt uncertain without acknowledgement of what had been done well (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). This aligns with Hattie and Timperley\u0026rsquo;s (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) recognition that feedback about \u0026ldquo;Self\u0026rdquo; (as a person) had little value in enhancing learning unless linked to processes or performance.\u003c/p\u003e\u003cp\u003eMost countries in this study have been impacted by a historical Confucian influence (\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e). \u0026lsquo;Confucian Heritage Culture\u0026rsquo; teaching is often stereotyped as having authoritarian teachers and obedient trainees who rote-learn (\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e). However, Confucian learning \u003cem\u003edoes\u003c/em\u003e value individuality, reflection and thinking as part of the learning process (\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e). Questioning is accepted, but only after thoughtful reflection which may require some time rather than questioning as an instant response. Clinical supervisors generally felt a responsibility to their trainees with a commitment to a tradition of passing expertise to the next generation, but felt feedback should be initiated by the supervisor, not sought by the trainee (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Scolding or punishment were viewed as an important component of providing feedback but potentially created \u0026ldquo;feedback phobia\u0026rdquo; resulting in an unwillingness to pursue feedback and demotivating trainees. As a result, they felt they were not trusted by their teachers, were incompetent in providing clinical care, thus reluctant to be involved with patients and impeding learning in the clinical environment. It is worth questioning whether harsh feedback practices stem from Culture, or the supervisors\u0026rsquo; own training experiences. We frequently teach the way we were taught.\u003c/p\u003e\u003cp\u003eHumiliating, negative feedback can lead to a fixed mindset, hindering learning and development (\u003cspan additionalcitationids=\"CR85\" citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e). Mindset refers to whether people see their abilities as fixed (\u0026lsquo;Fixed Mindset\u0026rsquo;) or can be improved (\u0026lsquo;Growth Mindset\u0026rsquo;). A person\u0026rsquo;s mindset is not permanent and can be modified (\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e). Trainees with a fixed mindset are grade-oriented and expect feedback to provide \u0026ldquo;correct\u0026rdquo; answers (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e) \u0026ndash; poor performance is attributed to a fixed ability rather than being improvable (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Feedback content and delivery shape the trainee\u0026rsquo;s mindset, so the supervisor can help the trainee develop their self-concept from poor ability to capability (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Harsh feedback can result in negative feelings and a superficial approach to learning which reinforces the fixed mindset (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e). Reports of specific Cultural effects on mindset are inconsistent and were not clearly identified in the included studies. However, a United Kingdom study involving local and international veterinary trainees examined mindset related to different curricular areas and found that Cultural background did not affect learning mindset in any areas of that curriculum (\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAttitudes to formal peer-to-peer feedback were ambivalent \u0026ndash; valued by some, distrusted by others, although this was discussed in a small number of the included studies. Structured peer-to-peer feedback for practical skills was beneficial and encouraged reflection on the skills assessed. Some trainees were concerned that peer feedback might lead them astray (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e), while in other circumstances, peer feedback was the most common feedback source (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis scoping review found little to contradict the \u003cem\u003eimportance\u003c/em\u003e of feedback for health profession trainees\u0026rsquo; clinical learning in non-Western settings, but Culture did affect feedback delivery by many supervisors, and trainees commonly were reluctant to seek feedback themselves.\u003c/p\u003e\u003cp\u003eThe experience at Universitas Gadjah Mada in Indonesia with the introduction of the Mini-Clinical Evaluation Exercise (Mini-CEX, an imported assessment tool) showed that contextualising this assessment to the local Culture enhanced feedback provision in a culturally appropriate manner (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHumiliating feedback did not enhance trainees\u0026rsquo; learning, contrary to the belief that it was necessary for trainees to learn, and to prepare them for the stresses of clinical practice. In a Western discussion of emotions and feedback provision, Ilgen and Davis (\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e) highlighted that negative feedback given without providing strategies for improvement resulted in learned helplessness. Asian trainees reported demotivation after scolding (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), disregarded harsh feedback (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e) and defined feedback as positive if it provided a path to improvement even when provided in a harsh manner (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Unconstructive feedback made trainees feel incompetent to participate in patient care and they avoided opportunities to learn (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWestern discussion of feedback (particularly over the past ten years or so) emphasises a need for dialogue and the trainee\u0026rsquo;s active role in seeking, reflecting on, and using feedback. Trainees need opportunities to apply feedback in practice and to develop self-assessment skills (\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e). The studies reviewed provided little evidence to contradict these key aspects of feedback, but feedback approaches need to be contextualised to local Culture and healthcare services. We suggest that Western clinical teaching could benefit by adapting group feedback practices to enhance learning.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications for further research\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFrom this scoping review we note that Culture, particularly power distance and collectivism, has an important impact on both trainee and supervisor conceptions about the place of feedback on learning in the clinical environment and results in predominantly \u0026ldquo;negative\u0026rdquo; feedback that is often harsh and punitive. Aspects of the healthcare system and education system cultures also influence preconceptions and negative (or absent) feedback. We observed tensions and contradictions in the way that feedback is perceived by trainees and their supervisors across Asia and the Middle East, with differences in approaches from that suggested as ideal in generic (\u0026lsquo;Western\u0026rsquo;) literature. We see the following as having potential to clarify feedback benefits across Cultures.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFurther research would be useful to identify other approaches to providing feedback in the high power distance, collectivist Cultures, and inform faculty development for clinical teachers.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFor the trainee who grew up in such Cultures and was schooled in a high power distance society, identifying effective approaches to encouraging feedback seeking, identifying feedback needs and using feedback provided could be valuable.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIt is also important to consider what pedagogical lessons Western clinical learning could take from Asia. Group feedback in collectivist Cultures provided benefits by generating group performance goals and provided a means to address performance difficulties involving several trainees. In a time-pressured learning environment, group feedback provided potential efficiencies.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIn the studies reviewed, there was little discussion about how feedback was used. Reflecting on feedback provided did not appear to be considered important. Further research may identify the place for encouraging reflection by trainees in the region, and if so, how should this occur? What is the concept of reflection in non-Western Cultures, and is reflection a key to using feedback in these Cultures?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe most obvious limitation to this review is that it was restricted to articles published in English. Due to our limited language proficiency and the absence of funding for translation, we were unable to include literature published in local languages. Locally published work could offer culturally nuanced insights into the role of feedback in education. The review was started when there were few studies of feedback in the region, but there has been an awakening of interest in this topic in Asia. We are hopeful that this review and our study informed by this review will provide ideas to enhance the provision and use of feedback within the region.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe importance of feedback is recognised widely and desired by trainees. Clearly there are both similarities and differences in the way feedback is conceived and provided in Western and Asian Cultures. Aspects of Culture do influence the way feedback is given and received. Using the Hofstede typology, high power distance and collectivism appeared to have the most obvious effects by inhibiting trainees from seeking feedback, requesting clarification of feedback given and thus dialogue. Collectivism, along with power distance and the impact of clinical service pressures, resulted in much feedback being given to trainees in groups. In this context group feedback had advantages in that using the feedback given became a group goal. We see this as having the potential to develop skills that would enhance future interprofessional collaboration in the clinical work environment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.7143%;\"\u003e\n \u003cp\u003eMeSH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.2857%;\"\u003e\n \u003cp\u003eMedical Subject Headings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.7143%;\"\u003e\n \u003cp\u003eMini-CEX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70.2857%;\"\u003e\n \u003cp\u003eMini-Clinical Evaluation Exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs this study is a literature review, ethics approval is not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot required\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003ePDF developed the original idea for this review in collaboration with MS, WM and SH, and later VN and VP. Initial screening of titles and abstracts and then full texts of retrieved articles was performed by PDF and MS, with input from WM and SH. Extraction of data and development of themes were performed by PDF, MS, VN and VP. PDF wrote the original draft of the review, which was subsequently refined by all authors. All authors agree to be accountable for all aspects of this review. PDF is guarantor of the review.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\n\u003cp\u003eWe would like to acknowledge the contributions of A/Prof Wendy McKenzie (WM) and A/Prof Shamsul Haque (SH) to the earlier development of this review.\u003c/p\u003e\n\u003cp\u003eClinical trial number: Not applicable.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAjjawi R, Regehr G. When I say \u0026hellip; feedback. 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BMC Med Educ. 2024;24(1):578. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12909-024-05598-6\u003c/span\u003e\u003cspan address=\"10.1186/s12909-024-05598-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Feedback, Culture, Cultural difference, Asia, Health Professions Education, Medical Education, Students, Health Occupations, Clinical clerkship","lastPublishedDoi":"10.21203/rs.3.rs-7074261/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7074261/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eFeedback is recognised as key to learning and development of health professionals. \u0026nbsp;However, most literature in this area originates in Western contexts, leaving a significant gap in understanding how Cultural factors influence feedback practices elsewhere. \u0026nbsp;This scoping review focuses on Asian contexts, where Cultural values and educational traditions shape the ways in which feedback is sought, provided, and received. The review explores how Culture in non-Western settings influences health professions trainees’ engagement with feedback during clinical training, as well as how supervisors' feedback practices are influenced by Cultural contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eFour databases — CINAHL, ERIC, MEDLINE and PsychINFO — were searched. The search, conducted up to June 2024, yielded 1241 citations, with an additional 51 identified through citation searching. \u0026nbsp;\u0026nbsp;Thirty-seven studies met inclusion criteria and were analysed. \u0026nbsp;A coding framework was developed and iteratively refined through team discussions to ensure analytic rigour.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe review identified three key, but interconnected, themes.\u003c/p\u003e\n\u003cp\u003e1) \u003cstrong\u003eImpact of Culture: \u003c/strong\u003e\u0026nbsp;Culture particularly power distance and collectivism, strongly influenced how feedback was perceived and enacted.\u003c/p\u003e\n\u003cp\u003e2) \u003cstrong\u003eDiverse perspectives and preferences about the place of feedback: \u0026nbsp;\u003c/strong\u003eTrainees had diverse perspectives and preferences regarding the place of feedback. \u0026nbsp;The role of group versus individual feedback appeared to be a significant difference from existing literature focussed on Western experiences.\u003c/p\u003e\n\u003cp\u003e3) \u003cstrong\u003eFeedback is seen as error identification, influenced by hierarchy and workload: \u003c/strong\u003e\u0026nbsp;Rather than fostering learning, feedback is viewed as shaped by hierarchical relationships and competing service demands.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eFeedback is valued by health professions trainees in Asian contexts, but its conception and practice differ from those typically described in existing literature (primarily of Western origin). \u0026nbsp;Cultural dimensions such as high power distance and collectivism contribute to variations in how feedback is sought, delivered, and understood. Recognising and adapting to these cultural influences is crucial for designing feedback practices that are meaningful and educationally effective in non-Western settings.\u003c/p\u003e","manuscriptTitle":"Cultural influences on non-Western health profession trainees seeking and receiving feedback: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-21 17:32:39","doi":"10.21203/rs.3.rs-7074261/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-20T05:11:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-17T17:52:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-16T06:16:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-11T22:19:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-08T10:08:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317877275549479960653404128221603538568","date":"2025-08-05T09:16:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13184511207752200517621208998572237915","date":"2025-08-04T23:01:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150911695258996611748097444069353246896","date":"2025-08-04T07:38:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180717694127991511708731389030497726640","date":"2025-08-01T07:09:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81143693871354661921381901155329783387","date":"2025-07-28T13:40:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-17T06:10:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-17T02:02:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-16T05:17:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-15T08:03:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-07-15T07:53:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"52c1c56d-f711-4598-bfe4-dccd7f879c7d","owner":[],"postedDate":"July 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:09:54+00:00","versionOfRecord":{"articleIdentity":"rs-7074261","link":"https://doi.org/10.1186/s12909-025-08307-z","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-11-29 15:58:02","publishedOnDateReadable":"November 29th, 2025"},"versionCreatedAt":"2025-07-21 17:32:39","video":"","vorDoi":"10.1186/s12909-025-08307-z","vorDoiUrl":"https://doi.org/10.1186/s12909-025-08307-z","workflowStages":[]},"version":"v1","identity":"rs-7074261","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7074261","identity":"rs-7074261","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}