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Continuing Competence Theory: Factors Influencing Responsiveness to Feedback

This article highlights research examining interpersonal factors influencing responses to feedback: namely the interplay between fear, confidence and reasoning processes.1

This is the fifth in a series on self assessment and feedback covering off a model of dimensions of informed self-assessment including external feedback, the impacts of peer assessment and feedback on performance improvement, quality improvement within physiotherapy organizations and the adoption of a clinical practice guideline.

Managers as well as practice and competence program leaders will find this research interesting because it explains, in part, why the same feedback strategy works for some individuals but not for others. Feedback delivery without considering the array of individual interpersonal and contextual factors influencing receptivity is just as likely to thwart rather than facilitate desired changes in performance.

Researchers have long understood that self assessment alone was inadequate for providing an individually generated summary of one’s abilities.2,3 Accurate external feedback has been touted as crucial to facilitate improvement. Consequently, they were interested in understanding the processes through which self-perception and external feedback interact to influence professional development. As feedback is inevitably interpreted through the lens of one’s self-perceptions, it is important to understand how learners interpret, accept and use feedback (or not) and the factors that influence those interpretations.

Study design and methods

This research was designed to elicit understandings of the processes used by learners and physicians to:

  1. Interpret, accept and use (or not) data to inform their perceptions of their clinical performance
  2. Further understand the factors (internal and external) believed to influence interpretation and uptake of feedback
  • 134 participants from eight health professional training/continuing competence programs were recruited to participate in 17 focus groups. 
  • Professions represented were Medicine and Midwifery from three undergraduate programs (53 individuals), two post graduate medical residency programs (32 individuals) and three practicing physician programs (49 family physicians and internists).
  • Focus groups used semi-structured interviews designed to elicit perceptions of self-assessment generally and the impact of the specific programs (i.e., learner feedback and continuing competence) with respect to their capacity to prompt meaningful reflection that could inform one’s self assessment and direct learning.


The ways in which participants interpreted external feedback both formal and informal, fell into several categories.

  1. Interplay between experience, confidence, and fear of not appearing knowledgeable
  2. Influence upon accessing, interpreting and using feedback
  3. Mechanisms guiding and potentially biasing interpretation for external feedback

Confidence, experience, and fear of not appearing knowledgeable

With respect to confidence, experience and fear of not appearing knowledgeable, each could have a paradoxical effect of both increasing and decreasing receptivity.

Discussions of the role of the self in judging one’s performance and the readiness to accept feedback from other sources, brought to light a fundamental difference of opinion across groups regarding how much learners and physicians should disclose to their patients, their colleagues, or themselves about their limitations.

Some argued that a lack of humility (i.e., the willingness to disclose one’s limitations) is a fundamental problem with some individual’s practice.

Others argued that one should not disclose a lack of knowledge to patients as desirable features of practice to be strived for include independence and the projection of confidence.”1

For learners, situations of not appearing knowledgeable was challenging. When assessing their competence in challenging situations, they balanced the risk to the patient and the implications of appearing incompetent to others if they reached out for help.

Physicians too expressed that fear of not appearing knowledgeable (“the fear of looking really stupid”) is a motivational factor for professional development and performance improvement.  

“With respect to enabling actual confidence, participants indicated a large number of factors influence their perceptions of their own performance, their motivations for wanting to perform well and their interpretation of externally generated information.”1 Experience was a central and critical theme as it was considered a fundamental determinant of whether or not one is able to perform certain tasks. Absolute number of cases seen and the occurrence of specific experiences were considered to be instrumental in enabling confidence. Because participants did not elaborate about the quality of the experience or information gained from experience, it seemed they perceived experience alone contributed to confidence and a sense of comfort.

For learners, experience was viewed positively, was desired and generally led to increased confidence. That said, confidence was tenuous and a loss of confidence in response to an event needed to be overcome.

Confidence in one’s abilities, both in terms of its fragility and participant’s desire for it, was a major theme regarding the role of feedback. Participants definitely wanted feedback from others, yet their statements implied that what they wanted was reassurance (i.e., feedback as a source of confidence building rather than a behavior correction strategy). While participants valued confidence, many acknowledged the risks of becoming over-confident and described how one’s confidence needs to be informed by honest and humble self-appraisals of how they are doing.

The responses suggested a paradox in that one needed to achieve a level of comfort, experience and confidence prior to being ready to ask for or receive corrective feedback. Confidence and experience worked in two ways by enabling participants to ask for and accept feedback and, for some, guarding them against feedback that might be critical in nature.

Influences on interpretation and uptake of external feedback

Participants expressed that confidence alone could be an unreliable indicator of ability. Physicians spoke of the need to be shaken out of a prior belief and experienced a feeling of “shock” upon discovery there was a weakness in their performance. Furthermore, they indicated a need to get over that feeling before the information could be utilized. Perceived credibility of the source contributed to the likelihood of external information being utilized as well as perceived accuracy of the feedback.

Perceived credibility of the source of external information was a factor increasing the likelihood of external information being utilized. Participants emphasized the perceived accuracy of feedback. Learners discounted feedback if the provider had not actually observed their performance. Similarly, family physicians commented on critical consultants who did not understand the family physician’s role and practice context and patients who lacked the medical knowledge or insight required to objectively judge care. Others indicated the lack of access to external feedback when one is in solo practice.

Paramount was the need to believe that feedback was delivered from a position of kindness and non-maleficence, with the belief based on experiences of strong relationships being established between feedback deliverers and recipients.

Mechanisms guiding (and potentially biasing) interpretation of external feedback

Participants expressed numerous reasons to “doubt the veracity of the external feedback received, thus reinforcing the notion that one must consider the recipient’s interpretation of the feedback conveyed if one hopes to alter their focal behavior.” 1

Doubt threaded into statements revealed potentially biased reasoning. While research design did not allow assessment of the accuracy of participant’s statements, their choice of words suggested ways in which reasoning about one’s own performance could be led astray. For example, some had a tendency to trust positive outcomes/feedback while discounting negative ones. They discounted that positive and negative outcomes can equally occur by chance. Adding to potential to bias were statements reminiscent of the tendency humans have to attribute negative outcomes to situational (external) factors while attributing positive outcomes to one’s own skill.1

Though the focus groups concentrated on using external information to facilitate self-assessment, many participants made overarching statements about their confidence in their experience and knowing enough. These statements suggested that they remained of the opinion that at some fundamental level they were able to judge for themselves whether or not they are fit to practice in specific situations.


Central themes around research into health professional’s interpretation of external feedback and its assimilation with self-perceptions were:

  • A dominant influence was confidence which allows one to hear potentially threatening appraisals but also gets in the way because people think they have to project it.
  • Confidence may lessen the extent to which external feedback that is inconsistent with one’s self appraisals is deemed credible.
  • Experience was integral to developing a sense of confidence.
  • Confidence was fragile and participants valued feedback mechanisms that maintained confidence akin to self-efficacy literature on the value of positive feedback.
  • Attempts to reconcile conflicts between external data and one’s own self-appraisal are variable and complex.
  • Experience, confidence and fear and biases inherent in cognitive reasoning processes can impact response to feedback. leading researchers to conclude that when it comes to providing feedback to health professionals it is equally if not more important to consider how feedback is received and data are interpreted than the strategies related to the delivery of feedback.

“… there is no simple recipe for the delivery of feedback. While most teaching around feedback focuses on delivery, feedback providers must learn to take into account the self-perceptions of the individual being assessed. If one hopes to convey feedback that is perceived as credible, an effort must be made to tailor feedback in a manner that will be interpretable and palatable through the lens of the recipient’s perceptions. Feedback appears most likely to be perceived as worthy of attention and action when delivered from a clear position of beneficence that allows the learner to maintain their self-concept. To enable this, it may be worth exploring how to efficaciously translate the notions of shared decision-making7 and relationship centred-care8, prevalent in the clinical world, into the educational process and the learner supervisor relationship.”

Relevance to physiotherapists in Alberta

  • Many physiotherapists receiving “results” from the continuing competence program audit over the past five years probably have opened that results letter with a mixture of fear and trepidation. Was the experience shocking or confidence building? Was hot or cold cognition in play? With the DO.LEARN.GROW program, the College of Physiotherapists of Alberta provides summative results. We cannot control perceptions of the information provided. Regulated members who have questions or feedback on audit results must contact the Competence Department for additional information tailored to their personal context.
  • Any physiotherapist in the business of providing feedback should bear in mind that for health professionals – most will want an affirmation that will improve their confidence and not feedback that may be critical of their performance.
  • A recipient’s emotional receptivity to feedback will be impacted by a mixture of fear, confidence and experience. If the receiver perceives that that the feedback provider is approaching the process from the perspective of beneficence and, better yet, has a good relationship with the provider, there is increased likelihood external data that the feedback provided will be used to inform changes in professional development and performance.

I fully acknowledge that most of the content from this article is directly paraphrased from Eva et.al 2012 article. Comments? Contact the Continuing Competence Program 780 438 0338 X 349


Hot Cognition: Related to emotion, arousal, and motivation, often relating to factors that protect or strengthen one’s perception of oneself. (i.e., self-serving bias that arises when people attribute failures of performance to situational factors and success to their own ability.)

Cold Cognition: Influences that arise from more analytical or unemotional ways in which attention, memory and judgement operate (e.g., Confirmation bias a tendency to test hypothesis in a one sided way)5,6

  1. Eva KW, Armson H, Holmboe E, Lockyer J, Loney E, Mann K, Sargeant J. Factors influencing responsiveness to feedback: on the interplay between fear, confidence, and reasoning processes. Advances in health sciences education. 2012 Mar 1;17(1):15-26.
  2. Davis DA, Mazmanian PE, Fordis M, Van Harrison RT, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. Jama. 2006 Sep 6;296(9):1094-102.
  3. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. Journal of personality and social psychology. 1999 Dec;77(6):1121.
  4. Sargeant J, Armson H, Chesluk B, Dornan T, Eva K, Holmboe E, Lockyer J, Loney E, Mann K, van der Vleuten C. The processes and dimensions of informed self-assessment: a conceptual model. Academic Medicine. 2010 Jul 1;85(7):1212-20.
  5. Gilovich T. How people know what isn’t so: The fallibility of reason in everyday life.1991
  6. Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. science. 1974 Sep 27;185(4157):1124-31.
  7. Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient education and counseling. 2006 Mar 1;60(3):301-12.
  8. Beach MC, Inui T, Care RC. A constructive reframing. Journal of General Internal Medicine. 2006 Jan;21:S3-8.

Page updated: 20/04/2022