Background: Trusting relationships between faculty and learners, described as an “educational alliance,” play an important role in constructive feedback. Such relationships can be difficult to achieve in current clinical learning environments (CLEs), which may diminish faculty members’ willingness to give learners feedback that supports their growth and performance. Our study seeks to explore the role of trust in faculty’s willingness to give constructive feedback to learners in CLEs.
Methods: In this constructivist qualitative study, we used trust as a sensitizing concept to explore how faculty decide whether and how to give constructive feedback to learners. We developed a semi-structured interview guide that asked faculty about their experiences working with and giving feedback to learners and their perceptions of the feedback culture in CLEs. We interviewed 23 physician-faculty from the department of medicine at an academic medical center from 11/2023 to 01/2024. We analyzed interview transcripts using Braun and Clarke’s reflexive thematic analysis.
Results: Participants described the importance of meaningful, longitudinal relationships for engaging in feedback. In the absence of these ideal relationships, participants expressed reluctance to give feedback based on 1) lack of trust in their own skills and judgment (e.g., not confident in ability to give feedback in a way learners can use to improve, not sure they have observed the learner enough to warrant the feedback), 2) lack of trust in learners as invested partners in learning (e.g., doubts about learners’ receptivity to feedback), and 3) lack of trust in programs and systems (e.g., concern that the program will not provide learners the support they need for improvement or will question faculty if feedback is poorly received). While not our primary focus, we also found themes about the risks associated with giving constructive feedback. These themes included concerns about risks to trainees (e.g., causing learners distress, delivering feedback that learners perceive as biased) and risks to the faculty members themselves (e.g., fear of “retribution,” guilt for upsetting learners). Amidst these concerns, participants also acknowledged that giving constructive feedback was generally “the right thing to do”, even if they were not willing to do so. Participants emphasized the need for structural and programmatic changes to improve faculty-learner relationships and facilitate constructive feedback.
Conclusions: Our findings suggest that faculty recognize the importance of constructive feedback for learners’ growth, yet they associate such feedback with risk to learners and to themselves. These risks reflect and contribute to lack of trust at the individual, interpersonal, and systems levels. Our findings highlight threats to achieving CLEs that sustain an educational alliance between faculty and learners and that reduce faculty willingness to deliver constructive feedback to learners, suggesting the need for a multipronged approach to improve feedback dialogue in CLEs.