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Navigating Discourses of Feedback: Developing a Pattern System of Feedback

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Title: Navigating Discourses of Feedback: Developing a Pattern System of Feedback
Language: English
Authors: Catherine Patocka (ORCID 0000-0003-4683-5655), Lara Cooke (ORCID 0000-0001-5417-571X), Irene W. Y. Ma (ORCID 0000-0002-7580-0171), Rachel H. Ellaway (ORCID 0000-0002-3759-6624)
Source: Advances in Health Sciences Education. 2025 30(3):755-775.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 21
Publication Date: 2025
Document Type: Journal Articles
Reports - Evaluative
Descriptors: Feedback (Response), Medical Education, Pattern Recognition, Educational Research
DOI: 10.1007/s10459-024-10376-6
ISSN: 1382-4996
1573-1677
Abstract: Although feedback is often presented as if it were a well-understood concept in health professions education, in practice it can mean many things. For some, feedback is a conversation about defining and improving performance, while for others it is the information generated by assessments and tools. Indeed, feedback has variously been defined as a process, as data, as a conversation, and as a reflective exercise. As a result, for a concept so central to what educators do, 'feedback' is ambiguous and has multiple meanings. Pattern theory affords opportunities to examine what scholars and practitioners mean when they use the term 'feedback'. Elaborating feedback as a pattern system can connect otherwise disjointed discourses of feedback. In this paper, the authors describe the development of a pattern system of feedback in medical education. Arksey & O'Malley's 5-stages of scoping reviews were adapted to enact a 6-step pattern system development methodology that included (1) Identifying the research question and scope of inquiry; (2) elaborating a strategy for pattern identification; (3) study selection; (4) abductive pattern representation development; (5) pattern system testing; and (6) summarizing and reporting the results. A pattern system of feedback was developed based on review of 218 full text articles and testing against an additional 2833 citations. This pattern system is made up of 36 pattern representations organized under 6 domains: feedback referent, feedback intentions, feedback information, feedback processing, feedback response, and feedback meta. The pattern system was applied to two models of feedback to demonstrate its utility as a lens through which to analyze various instances of feedback and to foreshadow its potential broader applicability as a tool to facilitate knowledge synthesis in the feedback problem space.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1484757
Database: ERIC
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  Value: <anid>AN0185469546;oak01jun.25;2025Jun02.02:37;v2.2.500</anid> <title id="AN0185469546-1">Navigating discourses of feedback: developing a pattern system of feedback </title> <p>Although feedback is often presented as if it were a well-understood concept in health professions education, in practice it can mean many things. For some, feedback is a conversation about defining and improving performance, while for others it is the information generated by assessments and tools. Indeed, feedback has variously been defined as a process, as data, as a conversation, and as a reflective exercise. As a result, for a concept so central to what educators do, 'feedback' is ambiguous and has multiple meanings. Pattern theory affords opportunities to examine what scholars and practitioners mean when they use the term 'feedback'. Elaborating feedback as a pattern system can connect otherwise disjointed discourses of feedback. In this paper, the authors describe the development of a pattern system of feedback in medical education. Arksey & O'Malley's 5-stages of scoping reviews were adapted to enact a 6-step pattern system development methodology that included (<reflink idref="bib1" id="ref1">1</reflink>) Identifying the research question and scope of inquiry; (<reflink idref="bib2" id="ref2">2</reflink>) elaborating a strategy for pattern identification; (<reflink idref="bib3" id="ref3">3</reflink>) study selection; (<reflink idref="bib4" id="ref4">4</reflink>) abductive pattern representation development; (<reflink idref="bib5" id="ref5">5</reflink>) pattern system testing; and (<reflink idref="bib6" id="ref6">6</reflink>) summarizing and reporting the results. A pattern system of feedback was developed based on review of 218 full text articles and testing against an additional 2833 citations. This pattern system is made up of 36 pattern representations organized under 6 domains: feedback referent, feedback intentions, feedback information, feedback processing, feedback response, and feedback meta. The pattern system was applied to two models of feedback to demonstrate its utility as a lens through which to analyze various instances of feedback and to foreshadow its potential broader applicability as a tool to facilitate knowledge synthesis in the feedback problem space.</p> <p>Keywords: Feedback; Conceptualization; Pattern system; Pattern theory</p> <p>Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s10459-024-10376-6.</p> <hd id="AN0185469546-2">Introduction</hd> <p>Providing feedback is an essential part of health professions education (HPE) (Archer, [<reflink idref="bib8" id="ref7">8</reflink>]). Although the HPE literature often refers to feedback as if it were generic and well-defined (Ende, [<reflink idref="bib22" id="ref8">22</reflink>]; van de Ridder et al., [<reflink idref="bib48" id="ref9">48</reflink>]), in practice, what feedback means can vary greatly (Ajjawi & Regehr, [<reflink idref="bib1" id="ref10">1</reflink>]; Archer, [<reflink idref="bib8" id="ref11">8</reflink>]). For some, feedback is information from haptic laparoscopic trainers (Perrone et al., [<reflink idref="bib38" id="ref12">38</reflink>]), for others it is a conversation about defining and improving performance (van de Ridder et al., [<reflink idref="bib48" id="ref13">48</reflink>]). Feedback has been defined as a process (Molloy & Boud, [<reflink idref="bib34" id="ref14">34</reflink>]), as information (Hattie & Timperley, [<reflink idref="bib26" id="ref15">26</reflink>]), as a conversation (Ajjawi & Regehr, [<reflink idref="bib1" id="ref16">1</reflink>]), and as a reflective exercise (Moroz et al., [<reflink idref="bib35" id="ref17">35</reflink>], [<reflink idref="bib36" id="ref18">36</reflink>]).</p> <p>The most obvious challenge stemming from a lack of common understanding of what 'feedback' means is that we cannot be certain that everyone is referring to, or thinking about, the same thing. This is particularly problematic when we aim to synthesize or apply the findings from various studies of feedback. Existing evidence syntheses of feedback in HPE have focused on defining (van de Ridder et al., [<reflink idref="bib48" id="ref19">48</reflink>]), re-defining (Ajjawi & Regehr, [<reflink idref="bib1" id="ref20">1</reflink>]), examining the outcomes of feedback interventions (Castro et al., [<reflink idref="bib17" id="ref21">17</reflink>]; Ivers et al., [<reflink idref="bib28" id="ref22">28</reflink>]; Kluger & DeNisi, [<reflink idref="bib30" id="ref23">30</reflink>]; Veloski et al., [<reflink idref="bib50" id="ref24">50</reflink>]), proposing best practice guidelines (Ende, [<reflink idref="bib22" id="ref25">22</reflink>]; Lefroy et al., [<reflink idref="bib31" id="ref26">31</reflink>]), theories (Watling, [<reflink idref="bib51" id="ref27">51</reflink>]), and frameworks (Brown et al., [<reflink idref="bib15" id="ref28">15</reflink>]; Cooke et al., [<reflink idref="bib18" id="ref29">18</reflink>]). However, each of these approaches tends to overlook the diverse meanings, interpretations, and complexity of feedback in favour of more straightforward generalizations. Consequently, these studies tend to offer a narrow and limited synthesis of evidence compromising the applicability of their interpretations to the broader landscape of feedback. Further complicating the matter, some scholars have proposed reframing our conceptions of feedback as "performance related information" or "learning conversations" (Tavares et al., [<reflink idref="bib46" id="ref30">46</reflink>]; van der Leeuw et al., [<reflink idref="bib49" id="ref31">49</reflink>]). While these approaches may be helpful in specific contexts, they may also inadvertently lead to practitioners and scholars talking past each other about the phenomenon they consider to be feedback (Spooner et al., [<reflink idref="bib45" id="ref32">45</reflink>]; Alansari et al., [<reflink idref="bib3" id="ref33">3</reflink>]). Little attention has (so far) been paid to this problem let alone what we might do about it. Rather than defining or re-defining what we mean by feedback (Ajjawi & Regehr, [<reflink idref="bib1" id="ref34">1</reflink>]; van de Ridder et al., [<reflink idref="bib48" id="ref35">48</reflink>]), we sought to unify these varied conceptualizations of feedback.</p> <p>We approached the problem using pattern theory (Ellaway, [<reflink idref="bib20" id="ref36">20</reflink>]). The concept of patterns as solutions to problems in a particular context, originates from the work of architectural theorist Christopher Alexander (Alexander, [<reflink idref="bib4" id="ref37">4</reflink>]) and has been used in fields such as architecture (Alexander, [<reflink idref="bib5" id="ref38">5</reflink>]; Scheurer, [<reflink idref="bib44" id="ref39">44</reflink>]), management (Becker, [<reflink idref="bib11" id="ref40">11</reflink>]), and computer science (Brown et al., [<reflink idref="bib14" id="ref41">14</reflink>]). More recently, Ellaway has elaborated a pattern theoretical approach that can capture these existing conceptions of pattern and deepen its epistemological and ontological bases (Ellaway, [<reflink idref="bib20" id="ref42">20</reflink>]). From this latter theoretical perspective, patterns can be understood as cognitive phenomena representing how humans perceive and understand regularities (Ellaway, [<reflink idref="bib20" id="ref43">20</reflink>]; Ellaway & Bates, [<reflink idref="bib21" id="ref44">21</reflink>]).</p> <p>Although patterns are cognitive phenomena, they can be externalized and shared amongst a collective such that form the basis of the shared thinking of the collective (Alexander, [<reflink idref="bib4" id="ref45">4</reflink>]; Ellaway & Bates, [<reflink idref="bib21" id="ref46">21</reflink>]; Iba, [<reflink idref="bib27" id="ref47">27</reflink>]). Exploring the apparent regularities in collective pattern thinking in a particular domain or context can inform different approaches to inquiry, including knowledge synthesis and primary fieldwork (Ellaway & Bates, [<reflink idref="bib21" id="ref48">21</reflink>]). When a pattern is written down, rendered as a diagram, framework etc. we call this a pattern representation. A collection of pattern representations that apply to a particular domain, topic, or area, and that function together is known as a pattern system (Ellaway, [<reflink idref="bib20" id="ref49">20</reflink>]). A pattern system can be expanded to become a pattern language by outlining a syntax (consisting of configurations and connections) between the pattern representations within it.</p> <p>Some concepts, if they are discreet and solve a single kind of problem, may be captured in a single pattern representation. However, broader concepts, such as competence or feedback, usually require multiple pattern representations to describe the various problems that need to be addressed and are better addressed using multiple pattern representations formulated as a pattern system. A pattern system can be formalized by systematically identifying, describing, and elaborating the pattern representations within it (Bates & Ellaway, [<reflink idref="bib10" id="ref50">10</reflink>]; Ellaway, [<reflink idref="bib20" id="ref51">20</reflink>]). If a pattern system is extended to include the apparent grammars and syntaxes that define how its pattern representations can and should be combined it becomes a pattern language.</p> <p>While definitions are about clarity and precision, pattern representations, pattern systems, and pattern languages are about shared understanding. To that end, pattern epistemology reflects Wittgenstein's concept of family resemblance in that we readily accept that many individuals belong to the same family even though they do not necessarily have any one feature or characteristic in common (Wittgenstein, [<reflink idref="bib52" id="ref52">52</reflink>]). For instance, in HPE, although we may each have differing beliefs and perceptions of what specifically constitutes feedback, we will likely share a similar 'patterned' understanding of its broad purposes, meanings, and characteristics. It is this shared understanding that allows us to discuss and develop ideas of feedback without having to hold to a single precise definition of what feedback is or should be.</p> <p>It was with this understanding of pattern theory and with an intention to deviate from existing narrow definitional approaches to feedback, that we sought to develop a patterned representation of feedback in HPE. In doing so, our goal was to facilitate a broader synthesis of the feedback literature and allow our field to move away from competing definitions and normative lists of ideal practices and outcomes (Ivers et al., [<reflink idref="bib28" id="ref53">28</reflink>]; Veloski et al., [<reflink idref="bib50" id="ref54">50</reflink>]) that are often difficult to translate into the diverse contexts of HPE (Watling, [<reflink idref="bib51" id="ref55">51</reflink>]). We also decided, for the sake of coherence, to focus only on medical education in this review.</p> <p>The aim of this study was to outline a pattern system of <emph>feedback in medical education</emph> made up of a series of pattern representations. We hypothesized that, even though there may not be a single quality shared by all instances of feedback, most if not all variant concepts of feedback would and should be able to be described using this common pattern system.</p> <hd id="AN0185469546-3">Methods</hd> <p>In formulating this study, we adapted scoping review methodology to generate a pattern system and its pattern representations.</p> <p>Although scoping reviews of feedback for learners in medical education have recently been conducted (Bing-You et al., [<reflink idref="bib12" id="ref56">12</reflink>]) rather than seeking to document the range and nature of feedback initiatives or the nature of the research effort, our methodological stance for conducting this review focused on mapping the regularities and elementary building blocks of phenomena that have been described as 'feedback' in the medical education literature. To that end, our goal focused on examining the extent, range, and nature (what we called the 'landscape') of the concept of feedback in medical education rather than on 'best practices' or on specific conceptualizations of feedback. This goal broadly aligned with a scoping review approach (Arksey & O'Malley, [<reflink idref="bib9" id="ref57">9</reflink>]; Levac et al., [<reflink idref="bib32" id="ref58">32</reflink>]) although we found we needed to make some adaptations to purposes and processes. In terms of purposes, Arksey and O'Malley ([<reflink idref="bib9" id="ref59">9</reflink>]) described four possible purposes of a scoping review: To examine the extent, range and nature of research activity, to determine the value of undertaking a full systematic review, to summarise and disseminate research findings, or to identify research gaps in the existing literature. We conceptualized our approach as constituting a fifth purpose, 'to outline the implied collective pattern thinking reflected in a body of research'. In terms of processes, we adapted Arksey and O'Malley's ([<reflink idref="bib9" id="ref60">9</reflink>]) five stages of scoping reviews as follows.</p> <hd id="AN0185469546-4">Stage 1: identifying the research question and scope of inquiry</hd> <p>At the outset of our study, we recognized feedback as an ambiguous concept and considered that pattern theory may be useful in confronting this problem; however, at this point we were not initially able to clearly define our research question. Instead, our pattern system development process began by defining the perimeters of the pattern area we would explore, which in turn established the scope of the review. We took it as axiomatic that patterns are implied (when not made explicit) in the shared actions and discourses of a field. To that end, the published literature on feedback was a logical basis for our review, as publications are a primary locus for educational scholarship and the rigour required of peer-reviewed articles make them more likely to include descriptions and justifications for their use of the concept of feedback.</p> <p>In defining the perimeters of our pattern area, we conducted a basic search of "feedback" and "medical education" in Ovid MEDLINE. Provisional review of the pilot search returns found substantial variance in how the term 'feedback' was used. Some of the instances that we encountered included feedback as an activity (i.e., a preceptor meeting with a learner to provide feedback), feedback as an artefact (various feedback devices such as haptic laparoscopic trainers or cardiopulmonary resuscitation feedback devices used in resuscitation), feedback as a role (students provide feedback to preceptors on their lectures), feedback as a construct (as a 'thing' that leads to improved learning and performance outcomes), and feedback as a structure (various algorithmic tools such as R2C2 (Sargeant et al., [<reflink idref="bib43" id="ref61">43</reflink>]) used to facilitate feedback conversations) – see Table 1. Given our focus on connecting different meanings and discourses of feedback, we decided that, despite the great variety (types) of the work we found, our pattern area was most comprehensively captured by all articles within medical education that matched to the term 'feedback' (rather than a specific subset). Once this pattern area had been articulated, we developed the review question as: "what is the implied pattern system of feedback as expressed in the medical education literature?".</p> <p>Table 1 Various framings of feedback encountered in medical education</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Artefacts</p></th><th align="left"><p>Activities</p></th><th align="left"><p>Roles</p></th><th align="left"><p>Concepts</p></th><th align="left"><p>Structures</p></th></tr></thead><tbody><tr><td align="left"><p>Mannequins</p><p>Task trainers</p><p>Cases</p><p>Slides</p><p>Cadavers</p></td><td align="left"><p>Assessment</p><p>Lectures</p><p>PBL</p><p>WBL</p><p>Interprofessional education</p></td><td align="left"><p>Teacher</p><p>Learner</p><p>Supervisor</p><p>Lecturer</p><p>Coach</p></td><td align="left"><p>Professionalism</p><p>Competence</p><p>Hidden curriculum</p></td><td align="left"><p>Syllabi</p><p>Curricula</p><p>Transcripts</p><p>Programs</p><p>Schools</p><p>Assessment tools</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0185469546-5">Stage 2: elaborating a strategy for pattern identification</hd> <p>Seeking to be comprehensive in identifying evidence that addressed the review question and reflected the scope of the pattern area, an initial search strategy was developed in collaboration with a health sciences librarian. The term "feedback" mapped to a number of Medical Subject Headings (MeSH) all of which were included in the search. The initial search was piloted on July 6, 2020 in Ovid MEDLINE using the terms ["feedback" OR "feedback, psychological" OR "feedback, sensory" OR "formative feedback" OR "knowledge of results, psychological" AND "Education, Medical"] and yielded 2100 citations. CP and RHE independently reviewed the title and abstract of the first 100 results to determine if the search captured different kinds of feedback in medical education. We noted that 78% of the time, broad philosophies of and perspectives on feedback could be gleaned from review of the title and abstract alone. Consensus on the remaining 22 articles was achieved through discussion within the study team. This search captured distinct kinds of feedback (variety), with some appearing more frequently than others (valence). Since the aim of our review was to maximally capture the varying concepts of feedback, at this stage we chose to sample for variance. Although we found no citations amongst these first 100 results that did not address or capture an aspect of feedback in medical education, in many cases, feedback was not the focus of the article.</p> <p>To ensure that our search strategy was capturing already identified key articles we also compared our pilot search results to the primary author's (CP) personal database of articles relevant to feedback and medical education, finding that several important articles relating to physicians' continuing professional development (considered by the authors to be a part of medical education) had not been captured. With some iterative testing, the search string was adjusted to include an additional heading of "Physicians" to address these omissions. The updated search was conducted on July 15, 2020 in Ovid MEDLINE and yielded 2461 citations. This second search captured all the key articles in CP's reference database. Given time and resource constraints, we only searched MeSH headings and excluded keyword searches. An updated search was conducted on January 4, 2022, and identified 447 additional citations.</p> <hd id="AN0185469546-6">Stage 3: study selection</hd> <p>Since our review aimed to capture the breadth (the extent or range) of the pattern area for feedback in medical education, almost every instance of that phenomenon (even if not empirical or the predominant subject of an article) was considered potentially relevant to developing the pattern system. However, with no way to articulate clear inclusion and exclusion criteria, we had a very large number of articles to review. We addressed this by reviewing an initial set of full text articles from which to derive the initial pattern system with the rest of the articles set aside to be used to elaborate the pattern system. This latter testing stage was moved to be the fifth stage of the review and was renamed 'testing the pattern system against the remaining literature'.</p> <p>As our focus was on capturing the breadth of perspectives and meanings of feedback, articles only needed to discuss the topic to be considered relevant. This contrasts with other systematic review approaches where articles that do not directly address the research topic are excluded at this stage. We also made no exclusions related to methodology. We derived the pattern system from an initial set of full text articles that included 3 groups: recent articles, foundational articles, and a snowball sampling of articles. Aiming to establish a pattern system of feedback that reflects contemporary perspectives, we initially examined the full text of the 75 most recent articles. Next, we checked the reference lists of these 75 articles for articles they used as foundations for their conceptualization of feedback. There were 1893 references identified in the reference lists of these 75 articles so for practical reasons only those references cited more than once (across the 75 reference lists) were reviewed. This process yielded a list of 91 articles which were added to the full text review corpus. Recognizing that the breadth of our research question limited any search strategy from comprehensively capturing it and recognizing that the search and study selection process in scoping reviews is iterative and requires reflexivity, we also used snowball searching to pursue additional relevant references. For instance, when an article referenced a particular theory, construct, or concept as being relevant to feedback, we sought its reference and added it to the full text review. This added an additional 63 articles. We ended up with a full text review corpus of 229 articles of which 11 were excluded (10 were not about feedback and 1 had inadequate information). In total we used 218 articles to develop our pattern system.</p> <hd id="AN0185469546-7">Stage 4: abductive pattern representation development</hd> <p>Diverging from Arksey and O'Malley's ([<reflink idref="bib9" id="ref62">9</reflink>]) process, we built on their principle that analysis requires some kind of organizing framework around which extractions can be analyzed. We used pattern representation development as that framework. This meant that, rather than charting using an existing conceptual framework, our review focused on generating the conceptual framework (as a pattern system). We iteratively, discursively, and inductively developed pattern representations and clusters of pattern representations which we termed pattern domains. We renamed this stage 'abductive pattern representation development' as it combined extraction and analysis in abductive cycles.</p> <p>We applied this abductive approach to synthesizing the 218 articles identified in our study selection phase (Kennedy, [<reflink idref="bib29" id="ref63">29</reflink>]), which combines elements of inductive and deductive reasoning to analyze data. We started by extracting details from the first twenty articles using Alexander's characterization of a pattern as a relationship between a particular context, a problem in that context, and a solution to that problem (Alexander, [<reflink idref="bib5" id="ref64">5</reflink>]). This produced a heterogeneous list of contexts, problems, and solutions that showed no apparent underlying order. We subsequently considered whether patterns of feedback could be better formulated as a process-oriented (or logic) model. To that end, much like a programme theory links programme inputs and activities to outcomes (Rogers, [<reflink idref="bib42" id="ref65">42</reflink>]), we developed our initial pattern system as an outline of the overarching causal chain of how activities labelled 'feedback' led to intended or observed outcomes. Our first draft pattern system logic model was rendered as a stepladder logic model with 7 distinct elements. As more articles were reviewed and more patterns were identified, we shifted to representing the patterns as descriptions of problem-solving thinking and practice in medical education. Once we had developed a stable system of outline pattern representations (based on article extractions that did not require any substantial revisions), we then moved to review the 90 foundational articles, thirty of which were coded by a second author (RHE) to draw out deeper details and implications. As a result, the draft pattern system went through several further revisions, primarily in terms of detailing and refining the pattern representations. This abductive process took several months. Each change was documented, elaborated in graphical models, and discussed within the team. At the end of this stage the pattern system was considered stable as only very minor refinements and adjustments were being made to its constituent pattern representations in response to the last articles we reviewed.</p> <p>Our approach to developing labels for our pattern representations was influenced by Wittgenstein's perspective that the meaning of a word is not fixed but dynamic and context dependent. Although we eschewed precise and rigid definitions, we also appreciated that some minimal form of conceptualization was required to guide our observations, to develop pattern representations, and to communicate our findings. The terminology we settled on was developed through abductive reasoning, discussion, and consensus of all authors (Kennedy, [<reflink idref="bib29" id="ref66">29</reflink>]).</p> <p>Recognizing that our use of terminology for pattern representations is similarly unstable and fluid, we also drafted a description for each pattern representation which included a short summary of its elements and any supporting empirical evidence. The final step was to check that all of the articles we reviewed had mapped to at least some of the 36 pattern representations and that all of the pattern representations mapped to at least some of the articles. We did this using an Excel spreadsheet (Microsoft<sups>®</sups> Excel for Mac, Version 16.73, 2023) with the 36 pattern representations as columns and the 218 articles as rows. The resulting matrix was populated by CP by pasting text from each article into the cell for the appropriate pattern representation. This mapping was reviewed iteratively by RHE and adjustments made as a result. This matrix was collated and summarized – see Appendix 2.</p> <hd id="AN0185469546-8">Stage 5: pattern system testing</hd> <p>This stage involved comparing sources not included in the original synthesis to test for fit and comprehensiveness and adjusting the draft pattern system to be inclusive of the broadening range of feedback examples. More specifically, having established in stage 2 that patterns of feedback could be gleaned from reviewing an article's title and abstract, we reviewed the titles and abstracts of the remaining 2833 articles. This involved using the 36 pattern representations as criteria to screen the remaining articles in hopes of identifying something new or different to add to our pattern system. CP and RHE first independently reviewed the title and abstract of the first 100 citations to ensure the feasibility of this approach, and, once established, CP completed the remaining reviews. Occasionally, when this information could not be determined from the citation alone, the full text was reviewed.</p> <hd id="AN0185469546-9">Stage 6: summarizing and reporting the results</hd> <p>This stage involved collating, summarizing, and reporting the results. As this required demonstration that our pattern system could be meaningfully applied to various models of feedback in medical education, we applied our pattern system to two well-described models of feedback (Sargeant et al., [<reflink idref="bib43" id="ref67">43</reflink>]; van de Ridder et al., [<reflink idref="bib48" id="ref68">48</reflink>]) using a modified framework analysis approach (Ritchie & Spencer, [<reflink idref="bib41" id="ref69">41</reflink>]) (where our pattern system served as the framework).</p> <hd id="AN0185469546-10">Results</hd> <p>We reviewed a total of 218 full text articles (see Fig. 1) in the development of the pattern system (see Appendix 1 for list of articles) and subsequently checked the draft pattern system against a further 2833 articles. The resulting pattern system consisted of 36 pattern representations (denoted in <emph>Italics)</emph> which we grouped into 6 domains ('Feedback Referent', 'Feedback Intentions', 'Feedback Performances', 'Feedback Processing', 'Feedback Response', and 'Feedback Meta') according to their approximate position in the varying feedback processes and models we reviewed (Table 2).</p> <p>Graph: Fig. 1 Flow diagram of study selection</p> <p>Table 2 Description of the 36 pattern representations</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Domain</p></th><th align="left" /><th align="left"><p>Pattern</p></th><th align="left"><p>Description</p></th></tr></thead><tbody><tr><td align="left"><p>Feedback Referent (REF)</p></td><td char="." align="char"><p>01</p></td><td align="left"><p>Facilitator competence</p></td><td align="left"><p>Explores feedback facilitator literacy</p></td></tr><tr><td align="left" /><td char="." align="char"><p>02</p></td><td align="left"><p>Subject competence</p></td><td align="left"><p>Explores the role for the subject in the feedback process</p></td></tr><tr><td align="left" /><td char="." align="char"><p>03</p></td><td align="left"><p>Infrastructure</p></td><td align="left"><p>Explores the organizational structures (policies, practices, norms) needed to support feedback</p></td></tr><tr><td align="left" /><td char="." align="char"><p>04</p></td><td align="left"><p>Purpose of the performance(s)</p></td><td align="left"><p>Describes what the subject is trying to do</p></td></tr><tr><td align="left" /><td char="." align="char"><p>05</p></td><td align="left"><p>Output of the performance(s)</p></td><td align="left"><p>Describes what the subject actually did</p></td></tr><tr><td align="left" /><td char="." align="char"><p>06</p></td><td align="left"><p>Performance measurement</p></td><td align="left"><p>Describes the measurement of the performance(s)</p></td></tr><tr><td align="left" /><td char="." align="char"><p>07</p></td><td align="left"><p>Sensor</p></td><td align="left"><p>Refers to the apparatus that detects the output of the performance(s)</p></td></tr><tr><td align="left" /><td char="." align="char"><p>08</p></td><td align="left"><p>Judgement</p></td><td align="left"><p>Refers to have the measurement form the sensor is interpreted</p></td></tr><tr><td align="left" /><td char="." align="char"><p>09</p></td><td align="left"><p>Results</p></td><td align="left"><p>Describes the results of the performance(s)</p></td></tr><tr><td align="left" /><td char="." align="char"><p>10</p></td><td align="left"><p>Specificity</p></td><td align="left"><p>Addresses the level of information presented in feedback messages</p></td></tr><tr><td align="left"><p>Feedback Intentions (INT)</p></td><td char="." align="char"><p>01</p></td><td align="left"><p>Purpose of the process</p></td><td align="left"><p>Addresses the intended or expected results of feedback</p></td></tr><tr><td align="left" /><td char="." align="char"><p>02</p></td><td align="left"><p>Function</p></td><td align="left"><p>Addresses the means through which the purpose of feedback is achieved</p></td></tr><tr><td align="left" /><td char="." align="char"><p>03</p></td><td align="left"><p>Assessment</p></td><td align="left"><p>Addresses whether there is a component of assessment in the feedback process</p></td></tr><tr><td align="left"><p>Feedback Information (INF)</p></td><td char="." align="char"><p>01</p></td><td align="left"><p>Source</p></td><td align="left"><p>Describes who or what is providing the information</p></td></tr><tr><td align="left" /><td char="." align="char"><p>02</p></td><td align="left"><p>Delivery</p></td><td align="left"><p>Addresses how the feedback message is formulated and delivered</p></td></tr><tr><td align="left" /><td char="." align="char"><p>03</p></td><td align="left"><p>Timing</p></td><td align="left"><p>Addresses the timing of feedback</p></td></tr><tr><td align="left" /><td char="." align="char"><p>04</p></td><td align="left"><p>Frequency</p></td><td align="left"><p>Addresses the frequency with which feedback is provided</p></td></tr><tr><td align="left"><p>Feedback Processing (PRO)</p></td><td char="." align="char"><p>01</p></td><td align="left"><p>Relationship</p></td><td align="left"><p>Addresses the relationship between the facilitator, subject and/or source</p></td></tr><tr><td align="left" /><td char="." align="char"><p>02</p></td><td align="left"><p>Self-directed assessment seeking</p></td><td align="left"><p>Addresses the personal responsibility the subject takes for looking outward</p><p>feedback from external sources</p></td></tr><tr><td align="left" /><td char="." align="char"><p>03</p></td><td align="left"><p>Self-assessment</p></td><td align="left"><p>Addresses whether the subject generates a judgment of their own ability</p></td></tr><tr><td align="left" /><td char="." align="char"><p>04</p></td><td align="left"><p>Attention</p></td><td align="left"><p>Describes that the learner has a choice to be aware of (or ignore) the information</p></td></tr><tr><td align="left" /><td char="." align="char"><p>05</p></td><td align="left"><p>Emotion</p></td><td align="left"><p>Addresses the emotional response to the information provided</p></td></tr><tr><td align="left" /><td char="." align="char"><p>06</p></td><td align="left"><p>Interpretation</p></td><td align="left"><p>Refers to the meaning-making process that the subject goes through</p></td></tr><tr><td align="left" /><td char="." align="char"><p>07</p></td><td align="left"><p>Credibility</p></td><td align="left"><p>Refers to the recognition that the subject has agency to assign trust and belief in the information</p></td></tr><tr><td align="left" /><td char="." align="char"><p>08</p></td><td align="left"><p>Discussion</p></td><td align="left"><p>Refers to the bi-directional, conversational nature of feedback</p></td></tr><tr><td align="left"><p>Feedback Response (RSP)</p></td><td char="." align="char"><p>01</p></td><td align="left"><p>Goal setting</p></td><td align="left"><p>Describes the object or aim of the response to feedback</p></td></tr><tr><td align="left" /><td char="." align="char"><p>02</p></td><td align="left"><p>Self-efficacy</p></td><td align="left"><p>Refers to the belief structure around one's capability to manage future situations</p></td></tr><tr><td align="left" /><td char="." align="char"><p>03</p></td><td align="left"><p>Unintended behaviors</p></td><td align="left"><p>Describes outputs or outcomes of feedback other than the intended purpose</p></td></tr><tr><td align="left" /><td char="." align="char"><p>04</p></td><td align="left"><p>Intention to change</p></td><td align="left"><p>Addresses the intentions of the subject to perform a behavior in response to feedback</p></td></tr><tr><td align="left" /><td char="." align="char"><p>05</p></td><td align="left"><p>Self-monitoring</p></td><td align="left"><p>Addresses the ability to respond to situations shaped by one's own capability at</p><p>that moment in that set of circumstances</p></td></tr><tr><td align="left" /><td char="." align="char"><p>06</p></td><td align="left"><p>Orientation</p></td><td align="left"><p>Addresses the orientation the subject takes towards the information</p></td></tr><tr><td align="left" /><td char="." align="char"><p>07</p></td><td align="left"><p>Actual action</p></td><td align="left"><p>Describes what actual action is taken in response to feedback</p></td></tr><tr><td align="left" /><td char="." align="char"><p>08</p></td><td align="left"><p>Outcome</p></td><td align="left"><p>Describes the outcome of the actions taken in response to feedback</p></td></tr><tr><td align="left"><p>Feedback Meta (MET)</p></td><td char="." align="char"><p>01</p></td><td align="left"><p>Culture</p></td><td align="left"><p>Addresses the values, beliefs, ideologies of the environment where feedback takes place</p></td></tr><tr><td align="left" /><td char="." align="char"><p>02</p></td><td align="left"><p>Recursion</p></td><td align="left"><p>Describes whether there are feedback loops/cycles</p></td></tr><tr><td align="left" /><td char="." align="char"><p>03</p></td><td align="left"><p>Context</p></td><td align="left"><p>Addresses the circumstances that form the setting for feedback</p></td></tr></tbody></table> </ephtml> </p> <p>The <bold><emph>'Feedback Referent</emph></bold>' domain addresses aspects of the performance(s) that feedback refers to, and it contains 10 pattern representations that reflect the stakeholders in a feedback process, the performance(s) feedback refers to, and the intentions, orientations, and measurements involved. The stakeholders in a feedback process include the subject (or recipient) of feedback and the facilitator (initiator, provider) of the feedback process. The '<emph>Subject Competence</emph>' pattern representation addresses the skill of subjects in navigating a feedback process, including those characteristics they have that may make them more or less receptive to feedback. The term "subject" was intentionally chosen (instead, say 'feedback receiver' or 'performer') to reflect that participants can be active subjects within a feedback process. The '<emph>Facilitator Competence</emph>' pattern representation addresses the skill and experience of the facilitators in providing feedback. The '<emph>Infrastructure</emph>' pattern representation reflects the organizational structures, policies, practices, and norms in which a feedback process occurs.</p> <p>There are three pattern representations in the '<bold><emph>Feedback Referent</emph></bold>' domain that deal directly with performance(s) of feedback. The '<emph>Purpose of the Performance(s)</emph>' pattern representation addresses what the subject is trying to do, the '<emph>Output of the Performance(s)</emph>' pattern representation addresses what the subject actually does, and the '<emph>Performance Measurement</emph>' pattern representation deals with how the subject's performance is measured or captured. For example, in a study aimed at using patient feedback to inform assessment and feedback to postgraduate trainees, investigators asked patients and their families to complete a modified Communications Assessment Tool (CAT) which involved rating 14 dimensions of a physicians' communication and interpersonal skills for any resident that had cared for them on an inpatient pediatric ward (Bogetz et al., [<reflink idref="bib13" id="ref70">13</reflink>]). In this example, the '<emph>Purpose of the Performance</emph>' pattern reflects residents' demonstrating communication and interpersonal skills, the '<emph>Output of the Performance</emph>' pattern reflects residents' provision of care on inpatient pediatric wards, and the '<emph>Performance Measurement</emph>' pattern reflects the use of the CAT evaluation tool.</p> <p>The '<emph>Sensor</emph>' pattern representation refers to the means used to detect the output of the performance, which can include mechanical instruments (e.g., a haptic laparoscopic simulator) as well as human observers (e.g., a teacher observing a performance). The '<emph>Judgement</emph>' pattern representation refers to how information from the sensor is appraised to produce an opinion about the performance (e.g., by the information programmed into a haptic laparoscopic simulator or by an observer of a performance). The '<emph>Results</emph>' pattern representation addresses the information about the performance that is communicated to the learner. This may include the outcome of the performance (reflecting the '<emph>Performance Measurement</emph>' pattern representation), but can also include a summary of performances (e.g., an aggregate report of all the CAT evaluations, analytics, etc.), ideal results (a correct answer or a required standard or benchmark), and possibly any naturalistic or actual results (e.g., a patient's condition worsens, a test result confirming a diagnosis, a patient's outcome). The '<emph>Specificity</emph>' pattern representation addresses the level of information presented in the feedback message, particularly the degree to which the information is task-, knowledge- or procedure-specific.</p> <p>The <bold><emph>'Feedback Intentions</emph></bold>' domain addresses the aim of the performance information and contains 3 pattern representations. The '<emph>Purpose of the Process</emph>' pattern representation reflects what the facilitator intends or expects from a feedback process. The '<emph>Function</emph>' pattern representation reflects the purpose of feedback, which may be directive (telling the subject what needs to be revised) or facilitative (providing comments and/or suggestions to help guide subjects). The '<emph>Assessment</emph>' pattern representation reflects any aspect of assessment involved (e.g., a grade or rating) in a feedback process.</p> <p>The '<bold><emph>Feedback Information</emph></bold>' domain addresses how the information is conveyed and contains 4 pattern representations. The '<emph>Source</emph>' pattern representation describes the source of the information (e.g., an individual or a computer program). The '<emph>Delivery</emph>' pattern representation reflects how the information is formulated and delivered to the subject. This includes how information is structured (e.g., narrative, numerical) and how it is conveyed (e.g., verbal, paper, electronic, etc.). The '<emph>Timing</emph>' and '<emph>Frequency</emph>' pattern representations address when and how often feedback occurs.</p> <p>The '<bold><emph>Feedback Processing</emph></bold>' domain addresses the means through which the subject processes the message and it contains 7 pattern representations. The '<emph>Relationship</emph>' pattern representation addresses the connection between the source of the information, the subject, and/or the facilitator. The '<emph>Self-directed Assessment Seeking</emph>' pattern representation reflects the subject of feedback taking responsibility for looking outward and seeking information from external sources, while the '<emph>Self-assessment</emph>' pattern representation addresses whether the subject generates a judgment of their own ability. The '<emph>Attention</emph>' pattern representation reflects the subject's engagement and attention (e.g., whether they choose to acknowledge or ignore the information provided). The '<emph>Emotion</emph>' pattern representation reflects the subject's emotional response to the information provided. The subject of feedback may go through a meaning-making process, in some cases referred to as reflection, which is captured in the '<emph>Interpretation</emph>' pattern representation. Through the reflection process, subjects may assess the '<emph>Credibility</emph>' pattern representation of the information and provider. At times, subjects and providers engage in a conversation, which is reflected in the '<emph>Discussion</emph>' pattern representation (e.g., to develop a shared understanding of the information and intention of feedback).</p> <p>The '<bold><emph>Feedback Responses</emph></bold>' domain includes the behaviours and actions of the subject in response to feedback and contains 7 pattern representations. The '<emph>Goal-setting</emph>' pattern representation reflects whether the subject sets goals for their future actions or behaviour while the '<emph>Self-efficacy</emph>' pattern representation reflects a subject's belief structure regarding their capability to embrace or seek change. The '<emph>Unintended Behaviours</emph>' pattern representation reflects subject actions or behaviours that were not predicted or intended by feedback designers/providers. The '<emph>Intention to Change</emph>' pattern representation reflects a subject's commitment to change. The '<emph>Self-monitoring</emph>' pattern representation addresses the subject's ability to monitor and regulate their behaviour in a particular situation. The '<emph>Orientation</emph>' pattern representation addresses the subject's overall orientation (growth, performance etc.) to feedback. The '<emph>Actions</emph>' pattern representation addresses tangible actions taken in response to feedback, while the '<emph>Outcome</emph>' pattern representation captures the outcomes of those actions.</p> <p>'<bold><emph>Feedback Meta</emph></bold>' domain captures the overarching influences of feedback and contains 3 pattern representations. The '<emph>Culture</emph>' pattern representation addresses the values, beliefs, ideologies of the environment where feedback takes place. The '<emph>Recursion</emph>' pattern representation reflects feedback processes that may involve multiple cycles where the feedback from one cycle informs both the performance and the feedback provided in subsequent loops. The '<emph>Context</emph>' pattern representation broadly addresses the circumstances, environment, and settings for a feedback process.</p> <hd id="AN0185469546-11">Applying the pattern system</hd> <p>To demonstrate how the pattern system can be used to examine, compare, and/or contrast unique instances of feedback we applied our pattern system to two well-described, evidence-based, highly cited models of feedback (Sargeant et al., [<reflink idref="bib43" id="ref71">43</reflink>]; van de Ridder et al., [<reflink idref="bib48" id="ref72">48</reflink>]).</p> <p>The first model we examined was the Relationship, Reaction, Content and Coaching (R2C2) framework, an evidence-based reflective model for providing feedback and coaching through learner engagement and collaboration between the feedback provider and recipient (<emph>R2C2 Guide</emph>, n.d.). We found that the R2C2 model mapped to 6 domains and 21 pattern representations of our pattern system (see Table 3) with no aspects of R2C2 that did not map to the system. Pattern representations from our system that were not explicitly addressed in the R2C2 model included subject competence, sensor, judgment, specificity, source, delivery, timing, frequency, self-directed assessment seeking, self-efficacy, unintended behaviours, self-monitoring, and orientation.</p> <p>Graph</p> <p>The second model was the operational model of feedback advanced by van de Ridder et al. ([<reflink idref="bib48" id="ref73">48</reflink>]) who defined feedback as: <emph>"specific information about the comparison between a trainee's observed performance and a standard</emph>,<emph> given with the intent to improve the trainee's performance"</emph>, and proposed ten key elements of feedback: performance and task; trainee; feedback provider; comparison between observed performance and a standard; observation; standard; specific information; intention; and improvement. We found that their model mapped to 4 domains and 11 pattern representations of our pattern system (see Table 3). Pattern representations that were not addressed in their model included infrastructure, output of the performance (s), performance measurement, judgment, assessment, delivery, timing, frequency, relationship, self-directed assessment seeking, self-assessment, attention, emotion, interpretation, credibility, discussion, goal setting, self-efficacy, unintended behaviours, intention to change, self-monitoring, orientation, actual action, outcome, and culture.</p> <p>Not only did both models of feedback map well to our pattern system, we found the mapping helpful in clarifying points of similarity and divergence of each model. That each model only reflected some aspects of the pattern system is not a criticism of those models. Rather, it is a recognition that different conversations and approaches to feedback have focused on specific aspects of the broader pattern system. This is not a weakness of any particular approach, but rather a reflection of the many overlapping conversations about feedback in medical education. That our pattern system was able to accommodate these differing perspectives provides validity evidence both for the approach and the product of this study.</p> <hd id="AN0185469546-12">Discussion</hd> <p>We have described our approach and rationale for outlining a pattern system of feedback in medical education. While pattern system and pattern language development is not a new concept (Alexander, [<reflink idref="bib4" id="ref74">4</reflink>]; Ellaway & Bates, [<reflink idref="bib21" id="ref75">21</reflink>]; Iba, [<reflink idref="bib27" id="ref76">27</reflink>]), previous studies have generally lacked detail in how pattern representations and systems were developed, and those that have provided more detail have tended to employ consensus methods and a normative approach (ideal practices) rather than review methods and a naturalistic approach (actual practices—see for instance Felstead & Thwaites, [<reflink idref="bib23" id="ref77">23</reflink>]). We therefore engaged in a degree of methodological innovation in this study, a process that continues in our own ongoing research and that we hope others will also explore.</p> <p>Our pattern system of feedback contains 36 pattern representations, which we organized into 6 domains. We derived the system from reviewing 218 articles and we tested it against an additional 2833 articles and 2 existing conceptualizations of feedback. Much like other theoretical frameworks for feedback, at first glance it may seem overwhelming (Brown et al., [<reflink idref="bib15" id="ref78">15</reflink>]; Kluger & DeNisi, [<reflink idref="bib30" id="ref79">30</reflink>]). However, we would argue that its size and complexity reflect the richness and depth of thinking and practice related to feedback in medical education. The size of our pattern system is also congruent with that of other pattern systems. For instance, Iba's ([<reflink idref="bib27" id="ref80">27</reflink>]) 'learning patterns' system contained 40 pattern representations intended to enhance creative learning, (Iba, [<reflink idref="bib27" id="ref81">27</reflink>]) while Alexander's ([<reflink idref="bib4" id="ref82">4</reflink>]) architectural pattern language, intended to serve as the guiding principles for all architectural design, included 253 pattern representations (Alexander, [<reflink idref="bib4" id="ref83">4</reflink>]).</p> <p>In terms of its application, the 36 pattern representations can serve as a lexicon of feedback for medical education, from which specific instances of feedback can be derived, much like sentences and paragraphs are formed from words. While every instance of feedback should reflect at least one of these pattern representations, every instance of feedback does not need to include all 36 pattern representations. Feedback <emph>may</emph> capture all these pattern representations, but more often it will include only a subset of the patterns, as illustrated by our mapping to the R2C2 and van de Ridder et al. ([<reflink idref="bib48" id="ref84">48</reflink>]) models of feedback. Indeed, this mapping process illustrated that each model had a different pattern syntax (pattern composition and arrangement), which provides a model through which their variances become apparent. For instance, researchers may explore why their syntax is different, what has led to the inclusion or exclusion of various pattern representations, why certain elements appear together, and what interactions they might have. It is through addressing these kinds of questions that we see pattern analysis as a promising approach to evidence synthesis in feedback. It is also important to note that in applying the pattern system to various instances of feedback we were not seeking to validate or invalidate any model or to agree or disagree with any model or approach; we used the pattern system as an analytic framework to illustrate the breadth of naturalistic thinking and practice around feedback, rather than any normative ideal feedback principles of practices.</p> <p>Rather than defining or re-defining our understanding of feedback, our pattern system aims to be inclusive of the variations, nuances, and complexities of feedback in medical education. We see our pattern system as a unified conceptual framing of feedback in medical education that may act as a higher-level guide for understanding the interrelationships between various feedback models and conceptualizations and in doing so may better facilitate evidence synthesis of feedback in medical education. For instance it may help us to understand, reconcile, and explore divergent definitions such as those proposed by (Molloy et al., [<reflink idref="bib33" id="ref85">33</reflink>], p. 34) who argued that feedback is a process where "learners obtain information about their work..." and Ajjawi and Regehr who argued that it is a "co-constructive interaction" rather than the provision of static information (Ajjawi & Regehr, [<reflink idref="bib1" id="ref86">1</reflink>], p.653).</p> <p>We would hope that the pattern system can also facilitate an expansion of integrative conversations and exploration to other HPE disciplines, which, although they have their own literatures, reflect similar variabilities in definitions and understanding of feedback that range from the theoretical (Plakht et al., [<reflink idref="bib39" id="ref87">39</reflink>]) to the practical (Hardavella et al., [<reflink idref="bib25" id="ref88">25</reflink>]). Indeed, in proposing a shared conceptual space around which findings and recommendations in feedback might be articulated, the pattern system may also help us to explore how context-dependent findings can be synthesized to improve our overall understanding of feedback. For example, it may inform how findings from a study exploring learner responses to feedback from haptic laparoscopic simulators might inform feedback in workplace-based assessments, competency-based assessment frameworks, or multisource feedback.</p> <p>In terms of the importance of this work beyond the specifics of feedback, medical education has long followed the path of evidence-based medicine in favouring precise taxonomic definition of concepts, judgments of value and quality grounded in methodological hierarchy, and statistical approaches to synthesis (Ellaway, [<reflink idref="bib19" id="ref89">19</reflink>]; Ivers et al., [<reflink idref="bib28" id="ref90">28</reflink>]; Veloski et al., [<reflink idref="bib50" id="ref91">50</reflink>]). We would argue that synthesis of evidence within medical education scholarship requires methods that are more flexible, inclusive, and accepting of our many fuzzy concepts and constructs. For instance, given that scoping reviews and realist reviews are increasingly common in our field as a pragmatic form of integrative scholarship (Ajjawi et al., [<reflink idref="bib2" id="ref92">2</reflink>]; Bing-You et al., [<reflink idref="bib12" id="ref93">12</reflink>]), there is a need for a unified conceptual understanding of the concepts and interventions that are being studied. We would suggest that approaching such work using a pattern epistemological and ontological frame, instead of trying to use precise taxonomic definitions, can help to advance integrative scholarship in general.</p> <p>We found a pattern theoretical approach offered a unifying, holistic epistemological approach for modeling the highly varied phenomenon of feedback as a single system as it was able to accommodate diverse perspectives and approaches without imposing conformity or demonstrating 'truth'. This is in distinction to other analytic frames, for instance discourse analysis, which aims to understand how language constructs meaning and how it reflects and shapes social reality (Paton et al., [<reflink idref="bib37" id="ref94">37</reflink>]). Indeed, we would argue that a pattern theoretical approach embraces variance in concepts and addresses why 'things the way they are' in terms of the interplay between structures, actions, and contexts (Archer, [<reflink idref="bib7" id="ref95">7</reflink>]).</p> <p>We should be clear however, that pattern representations are not about hard definitions; they are about shared recognition of regularities in our practices and the contexts in which they take place and as such offer a more flexible system of capturing the multiple methodological and philosophical approaches within medical education. It is our hope that pattern systems and subsequent pattern language delineation will facilitate synthesis of the feedback literature and enable us to capture a greater understanding of "how" processes like feedback and its related concepts (coaching, debriefing, multisource feedback etc.) may work in the various contexts of medical education.</p> <p>We are not the first to appreciate disjointed descriptions and elaborations of feedback within HPE. Tavares et al. ([<reflink idref="bib46" id="ref96">46</reflink>]) hinted at the inherent value of pattern thinking in their proposal to reframe feedback and debriefing as 'learning conversations'. We agree that conceptual clarity is of paramount importance to our field, but highlight the potentially problematic trend of scholars choosing to rename or reframe concepts of feedback (Tavares et al., [<reflink idref="bib46" id="ref97">46</reflink>]; van der Leeuw et al., [<reflink idref="bib49" id="ref98">49</reflink>]) when they encounter discord that doesn't conform to certain observations. We argue that we should have tools or models that allow us this flexibility. We believe that our pattern system of feedback affords a new way of looking at our concepts and routines. This includes elaborated conceptions of feedback such as 'learning conversations' and 'performance related information' to consider where their boundaries are and how they develop and change over time. It also stays true to the flexible repertoire and adaptable palette concept that can be used to generate new forms and practices in response to new or emerging needs.</p> <p>Pattern systems were proposed by Ellaway and Bates ([<reflink idref="bib21" id="ref99">21</reflink>]) to make sense of complex constructs and enable critical engagement with many of the underlying issues in our field. To that end they proposed a provisional pattern system of medical education patterns derived from four general medical education textbooks. This current study built on that work by outlining a rigorous and defensible methodological approach to pattern system development and demonstrating its application to the concept of feedback. Our approach may or may not prove to be definitive, but it is, we argue, an important step in opening this new methodological space. Moreover, although pattern languages have yet to be described or used in medical education, they have appeared in architecture, software design, and human activity (Alexander, [<reflink idref="bib4" id="ref100">4</reflink>]; Brown et al., [<reflink idref="bib14" id="ref101">14</reflink>]; Iba, [<reflink idref="bib27" id="ref102">27</reflink>]). Within architecture, Alexander's pattern language continues to be used as the basis for campus community planning at the University of Oregon (Alexander, [<reflink idref="bib4" id="ref103">4</reflink>]; Alexander et al., [<reflink idref="bib6" id="ref104">6</reflink>]; <emph>University of Oregon</emph>, n.d.) whereas pattern languages in software design have enabled a common base for understanding what is important and providing a corpus of patterns that enables programmers to solve problems more rapidly (Gabriel & Tetsuo, [<reflink idref="bib24" id="ref105">24</reflink>]). Iba ([<reflink idref="bib27" id="ref106">27</reflink>]) has created pattern systems and languages describing human actions in domains such as learning, collaboration, and presentation with the stated purpose of enabling more comprehensive understanding, conversation, and reflection. As we proceed in work developing our pattern system into a pattern language of feedback, it will be important to look to experiences in these fields where pattern languages are more elaborated to inform the use of patterns and pattern methodologies in medical education.</p> <hd id="AN0185469546-13">Limitations</hd> <p>In this study we outlined a pattern system of feedback, but this is not necessarily the end point of a program of pattern inquiry. This might be eventually developed into a pattern language, but to do so much more work would be needed to understand and interpret the depths and implications (if any) of different feedback pattern syntaxes reflected in which pattern representations interact and in what configurations. This exploration might be accomplished by using the pattern system as a lens through which to examine existing literature or as a theoretical model for empirical research.</p> <p>We also acknowledge several limitations with regards to our methodological choices. While we intended to be as comprehensive as possible in identifying literature suitable for answering our research question, from a practical point of view, decisions of how much to review had to be made. Broad searches of the term "feedback" could easily yield tens of thousands of results, time and budget constraints would have made a review of this magnitude unfeasible. As with any search of the literature, we acknowledge the possibility of selection bias in our methods but would welcome and encourage the identification of additional literature that evolves our pattern system. A pattern system is never complete, new evidence could emerge tomorrow that might lead us to re-interpret one or more elements, but this is both a challenge and affordance of any theoretical construct.</p> <p>Regardless of the rigour, pattern representations and pattern systems can only ever be provisional and fluid rather than absolute. Each representation is a conceptual nexus with its label and description reflecting the apparent shared pattern thinking in that nexus rather than it being a distinct conceptual identity. The labels we used, although tested and adapted for fit, are less important and less central than the nexus to which they are attached. It remains to be seen whether this fluidity will impact how stable, current, and widely applicable a pattern system can be. It was not feasible to review the full text of the 2833 citations, moving chronologically backwards from the most recent literature, we adopted a rigorous and practical approach wherein 218 full text articles were reviewed.</p> <p>We also acknowledge that pattern system mapping is an interpretive hermeneutic process (Caputo, [<reflink idref="bib16" id="ref107">16</reflink>]), and that others may have different interpretations of what should constitute a particular pattern representation or how it maps to practice. Nevertheless, our derivation was conducted in a rigorous, defensible, and well documented manner. The value of a pattern system rests in its utility for advancing understanding of feedback, having now done the extensive work to develop the pattern system, we welcome scholarly debates about our interpretations, and we look forward to conducting further studies to demonstrate the affordances and utility of the pattern system.</p> <p>Finally, we grounded our work in the scoping review methodology, proposing that pattern development could constitute a fifth rationale—beyond the four elucidated by Arksey and O'Malley ([<reflink idref="bib9" id="ref108">9</reflink>])—for embracing this approach. However, we acknowledge the possibility that the development of pattern systems might be better suited as a standalone systematic review methodology. We also acknowledge that in being the first to explore this methodology our approach may have been less straightforward than may be expected from further work. For instance, in the early stages of the methods section we elaborate extensively on how we came to articulate our research question, this step may be much less challenging for others who aim to employ this methodology in the future. However, we do reiterate that we have elaborated a methodology (an approach to pattern development) rather than a rigid method. Seen in this way we would expect that authors who aim to engage in pattern development work to dedicate care and consideration of the optimal approach (for instance some pattern development work may benefit more from consensus work and dialogue rather knowledge synthesis work) and authors should be clear in the justification for their methodological approaches. Future work could focus on elaborating further validity evidence for this methodology by demonstrating its utility to other activities, processes, and concepts.</p> <hd id="AN0185469546-14">Implications</hd> <p>Through this review we endeavoured to systematically identify and express the regularities of feedback in medical education and the variety in how those regularities are realised, in hopes that it would enable a shared conceptual framework upon which to base an evidence synthesis. Relevant and meaningful evidence synthesis remains an important challenge in medical education. Pattern systems have the potential to help scholars better delineate the landscape of our conceptualization in medical education and develop relevant and defensible integrative scholarship. Moving from a pattern system to pattern language may provide us with greater understanding of "how" a process like feedback works and how it can be used by medical educators to their advantage.</p> <hd id="AN0185469546-15">Conclusions</hd> <p>This paper is part of our emerging research programme looking at pattern thinking in medical education scholarship. By elaborating a 36-item pattern system of feedback in medical education, we are now positioned to explore how such a pattern system might facilitate more meaningful evidence synthesis and might start to address "how" processes like feedback work. Pattern systems provide essential infrastructure through which to better examine concepts such as feedback and we envision this work acting as a catalyst to advance the development and use of pattern theoretical approaches in medical education and in HPE.</p> <hd id="AN0185469546-16">Reflexivity statement</hd> <p>CP is an emergency physician who previously completed a Masters in health professions education within a post-positivist paradigm and with a focus on quantitative methods. She was disappointed that this existing work focused more on demonstrated whether something "worked" rather than explaining how it worked. She recently completed her PhD in medical education at the University of Calgary hoping to develop a greater understanding of varied paradigmatic and methodological approaches to confronting challenges in post-certification medical education settings. She became interested in feedback after her clinical department began providing its members with performance feedback that was promoted as a means to encourage practice reflection but was also used for performance management and assessment. While she undertook her doctoral work in hopes of bringing greater clarity to performance feedback in professional medical practice settings, her inability to align with any of the previously proposed definitions of feedback articulated in higher education and HPE, led her to focus instead on conceptual work aimed at elaborating feedback using a patterned perspective. RHE is a generalist medical educator with strengths in theory, qualitative methods, and medical education systems whose recent work has focused on elaborating pattern theory. LC is a neurologist, medical leader, and education scholar with active interests in audit and feedback, and IWYM is a general internist, education scholar, with active interests in competency-based education, assessment, and point of care ultrasonography.</p> <hd id="AN0185469546-17">Acknowledgements</hd> <p>The authors would like to acknowledge the Canadian Institute of Health Research (CIHR) and Royal College of Physicians and Surgeons for funding this work.</p> <hd id="AN0185469546-18">Author contributions</hd> <p>All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by CP and RHE. The first draft of the manuscript was written by CP and all authors commented on previous versions of the manuscript. All authors read and approved the revised final manuscript.</p> <hd id="AN0185469546-19">Declarations</hd> <p></p> <hd id="AN0185469546-20">Competing interests</hd> <p>Financial interests: Catherine Patocka received a 2019-2020 Doctoral award from the Canadian Institute of Health Research (CIHR) (ID 434817) and a Royal College of Physicians and Surgeons of Canada Robert Maudsley Fellowship in Medical Education Award. Lara Cooke, Irene Ma, and Rachel Ellaway declare they have no financial interests. Non-financial interests: Rachel Ellaway is the Editor of Advances in Health Sciences Education.</p> <hd id="AN0185469546-21">Electronic supplementary material</hd> <p>Below is the link to the electronic supplementary material.</p> <p>Graph: Supplementary Material 1</p> <hd id="AN0185469546-22">Publisher's note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0185469546-23"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Ajjawi R, Regehr G. When I say... feedback. Medical Education. 2019; 53; 7: 652-654. 10.1111/medu.13746</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Ajjawi R, Kent F, Broadbent J, Tai JHM, Bearman M, Boud D. Feedback that works: A realist review of feedback interventions for written tasks. 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  Data: Although feedback is often presented as if it were a well-understood concept in health professions education, in practice it can mean many things. For some, feedback is a conversation about defining and improving performance, while for others it is the information generated by assessments and tools. Indeed, feedback has variously been defined as a process, as data, as a conversation, and as a reflective exercise. As a result, for a concept so central to what educators do, 'feedback' is ambiguous and has multiple meanings. Pattern theory affords opportunities to examine what scholars and practitioners mean when they use the term 'feedback'. Elaborating feedback as a pattern system can connect otherwise disjointed discourses of feedback. In this paper, the authors describe the development of a pattern system of feedback in medical education. Arksey & O'Malley's 5-stages of scoping reviews were adapted to enact a 6-step pattern system development methodology that included (1) Identifying the research question and scope of inquiry; (2) elaborating a strategy for pattern identification; (3) study selection; (4) abductive pattern representation development; (5) pattern system testing; and (6) summarizing and reporting the results. A pattern system of feedback was developed based on review of 218 full text articles and testing against an additional 2833 citations. This pattern system is made up of 36 pattern representations organized under 6 domains: feedback referent, feedback intentions, feedback information, feedback processing, feedback response, and feedback meta. The pattern system was applied to two models of feedback to demonstrate its utility as a lens through which to analyze various instances of feedback and to foreshadow its potential broader applicability as a tool to facilitate knowledge synthesis in the feedback problem space.
– Name: AbstractInfo
  Label: Abstractor
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  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1484757
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1484757
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1007/s10459-024-10376-6
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 21
        StartPage: 755
    Subjects:
      – SubjectFull: Feedback (Response)
        Type: general
      – SubjectFull: Medical Education
        Type: general
      – SubjectFull: Pattern Recognition
        Type: general
      – SubjectFull: Educational Research
        Type: general
    Titles:
      – TitleFull: Navigating Discourses of Feedback: Developing a Pattern System of Feedback
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Catherine Patocka
      – PersonEntity:
          Name:
            NameFull: Lara Cooke
      – PersonEntity:
          Name:
            NameFull: Irene W. Y. Ma
      – PersonEntity:
          Name:
            NameFull: Rachel H. Ellaway
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      – BibEntity:
          Dates:
            – D: 01
              M: 06
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 1382-4996
            – Type: issn-electronic
              Value: 1573-1677
          Numbering:
            – Type: volume
              Value: 30
            – Type: issue
              Value: 3
          Titles:
            – TitleFull: Advances in Health Sciences Education
              Type: main
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