Feedback Literacy and Self-cognition Mechanisms Among BSc Medical Students: A Qualitative Analysis Based on the Johari Window Model

The Four quadrants of awareness

The Open Area, often referred to as the Arena, encompasses information about behaviours, skills, and attitudes known to both the student and the tutor. In this space, communication is transparent, and feedback typically involves mutually recognised performance gaps. Feedback falling into this quadrant is processed within a shared logical framework, making it the most conducive to rapid internalisation.¹¹

The Blind spot contains traits or behaviours visible to the tutor but hidden from the student. This is arguably the most critical area for clinical training, as it involves patterns the student is unaware of, such as poor body language or procedural oversights. Feedback here is often met with ‘Ego-Shock’ because it challenges the student’s existing self-perception.

The Hidden Area, or the ‘Façade,’ represents information known to the student but intentionally or unintentionally withheld from the tutor. This includes personal stressors, undisclosed academic struggles, or private intentions.¹⁵ When feedback is given without awareness of this context, it creates a ‘Contextual Mismatch’ that can lead to high resistance.

The Unknown Area consists of potential, feelings, or talents that are hidden from both the student and the tutor. In educational terms, this quadrant represents the ‘Zone of Proximal Development’ or latent clinical intuition that may only emerge under specific stress or mentorship.

Justification for the framework

The Johari Window is the superior framework for this study because it explicitly addresses the ‘Informational Asymmetry’ inherent in medical education. Unlike simpler models of communication, it accounts for the power dynamics and the trust required to move information from the Blind or Hidden areas into the Open Area. Furthermore, it integrates seamlessly with Kelman’s Social Influence Theory, which distinguishes between compliance, identification, and internalisation. By using the Johari Window, the researchers could track the movement of feedback information not just as a piece of data, but as a shift in the student’s self-cognition and identity. This framework allows for a multi-dimensional analysis of why certain students thrive on critique while others retreat into defensive perfunctory compliance.

Participant selection and context

Fourteen undergraduate students (aged between 20 and 25) enrolled in a Bachelor of Science (BSc) Medical Science programme were recruited via purposive sampling. Purposive sampling was chosen to ensure that the participants had relevant, diverse, and rich experiences with negative feedback in clinical or laboratory settings.¹⁸ The sample included a mix of international and domestic students, providing a broad perspective on the cultural and linguistic dimensions of feedback literacy. All participants had completed at least one clinical rotation and had received formal corrective feedback within the preceding six months.²¹

Data collection and instruments

The primary data collection tool was the semi-structured interview, which allowed for a consistent yet flexible exploration of the students’ self-cognition.⁴ Interviews were conducted by a trained qualitative researcher with a background in medical education, ensuring that the interviewer understood the specific clinical contexts described by the students.¹⁰ To maintain reflexivity, the interviewer maintained a journal of their own biases and assumptions throughout the process.¹⁹

The interview guide focused on specific ‘Feedback Incidents.’ Participants were asked to recall a time they received negative feedback and were guided through the following themes:

Interviews lasted between 45 and 75 minutes, were audio-recorded, and transcribed verbatim by a professional service.¹⁹ Transcripts were returned to participants for ‘Member Checking’ to ensure that the recorded narratives accurately reflected their internal experiences.²⁰

Within seven days following the interviews, participants completed a one-time reflective writing exercise. This documented their cognition, emotions, and behavioural changes regarding the same feedback experience, with participants marking corresponding Johari Window quadrants to facilitate cross-validation with interview data.

Data analysis and rigour

The analysis followed Braun and Clarke’s six-step framework for reflexive thematic analysis.¹⁶ First, the researchers familiarised themselves with the data through multiple readings of the transcripts. Second, initial codes were generated, focusing on emotional, cognitive, and behavioural markers. Third, these codes were collated into potential themes based on the Johari Window quadrants. Fourth, the themes were reviewed and refined to ensure they were supported by the raw data. Fifth, themes were clearly defined and named. Finally, the findings were synthesized into a coherent narrative.¹⁶

To ensure methodological rigour, several strategies were employed:

Ethical considerations

The study protocol was approved by the Institutional Ethics Committee. Participants provided written informed consent prior to the interviews.¹⁹ Confidentiality was strictly maintained by using pseudonyms or participant numbers (e.g., Participant 1, Participant 10) and by removing identifying institutional or patient details from the transcripts.¹⁹ Participants were informed of their right to withdraw from the study at any point without academic repercussions.²¹

Characteristics of feedback internalisation across quadrants

The first research question examined the emotional, cognitive, and behavioural markers that define how students process feedback within each Johari pane. Table 1 suggests that the ‘Open Area’ provides the most stable path to change, while the ‘Blind Spot’ and ‘Hidden Area’ introduce significant psychological friction.

The Open Area is characterised by ‘Rational Validation’. Participant 1, an international student receiving feedback on their writing method - specifically the habit of translating from their native Chinese to English - responded with immediate agreement. In their reflective diary, the student noted, “I am not surprised with the feedback as this phenomenon is not really good with in an English class,” demonstrating that internalisation occurs rapidly when the student already perceives the habit as sub-optimal. Because the student already knew this ‘was not really good,’ the feedback was not perceived as an attack. Cognitively, the student engaged in ‘Rational Alignment,’ comparing the tutor’s critique against their internal performance database and finding a high degree of congruence. This was evident in the student’s admission: “I just think he was right because that’s actually what he thought before… so I quite agree to what he said”. Behaviourally, this resulted in a long-term commitment to change that persisted even when the tutor was not present.

In the Blind Spot, feedback targets behaviours the student is deluded about, leading to ‘Ego-Shock’. Participant 10, who prepared a meticulous presentation only to be told they were ‘reciting from memory’ without depth, felt intense embarrassment. This reaction was captured in their reflection: “I felt surprised, upset, and, more than anything, embarrassed. I thought I had already done a pretty good job, so it was hard to hear that there were problems I hadn’t even noticed before.” Cognitively, this student had to resolve the dissonance between ‘I am a hard worker’ and ‘My work lacks depth’. Successful internalisation occurred only after the student depersonalised the critique and analysed the tutor’s perspective, concluding that “the issues my advisor pointed out were objectively real. I just found them hard to accept at first because being questioned in that moment made me defensive”. This cognitive shift eventually allowed them to reorganise their entire delivery strategy for future reports.

Feedback in the Hidden Area often results in ‘Psychological Reactance’. Participant 3 felt ‘extremely uncomfortable’ when a supervisor demanded extra IELTS vocabulary work during a high-pressure semester start. The student’s frustration was clear in their reflective writing: “I felt that spending about an hour each day memorizing words was a huge burden for me… On the one hand, it took up a lot of time, and on the other hand, I felt it was difficult psychologically”. Because the supervisor was unaware of the student’s actual workload (the Hidden context), the student viewed the feedback as a threat to their autonomy. Cognitively, students in this area use ‘Strategic Filtering,’ acknowledging the technical accuracy of the feedback but rejecting its contextual validity. This led Participant 14 to attend class after a warning (surface compliance) but to ‘still not pay attention’. Participant 14 summarised this failure of external influence, noting, “It is difficult to change people’s established habits and attitudes simply through external reminders”.

Differences in internalisation and causal mechanisms

The second research question addressed why internalisation rates vary so significantly across the quadrants. As shown in Table 2, the thematic data identifies trust, information symmetry, and identity threat as the primary drivers of these differences.

As can be seen in Table 2, the primary reason for the difference in internalisation is Information Symmetry. In the Open Area, symmetry is high, meaning the tutor and student share a common mental model of success. In the Blind Spot and Hidden Area, informational gaps create ‘Dissonance’ that students find difficult to bridge without a high degree of trust. For instance, if a student does not trust their tutor’s intentions or expertise, they will reject the feedback regardless of its objective accuracy. Participant 4 illustrated this rejection after finding previous guidance unhelpful: “Another reason is that I have found previous tutor feedback rather limited and sometimes difficult to understand.” This lack of trust led to a persistent mismatch where the student “understood the requirements from [their] own perspective, yet the tutor held different expectations and standards.”

Another major causal factor is the Preservation of Identity. Negative feedback in the Blind Spot threatens the student’s ‘Competence Identity’ (e.g., ‘I am not as good as I thought’), while feedback in the Hidden Area threatens their ‘Autonomy’ (e.g., ‘I am being controlled without my context being understood’). Participant 8 highlighted how feedback that ignores individual context can feel like a personal attack: “I felt discouraged and personally criticised… I strongly disliked being compared with other student groups.” According to Self-Determination Theory (SDT), internalisation requires the satisfaction of autonomy, competence, and relatedness. Feedback in the Hidden Area typically thwarts all three, leading to ‘Amotivation’ and perfunctory compliance.

Finally, the Cognitive Load of the feedback content plays a role. The data showed that feedback on ‘Technical Procedures’ was more easily internalised because it was concrete and observable. Participant 11, who was corrected on physical examination steps, admitted their operational flaws were easy to rectify, stating there were “no difficulties at all. I simply practised repeatedly until I became familiar with the procedures.” In contrast, feedback on ‘Attitudes’ or ‘Preparation Philosophy’ required deeper critical thinking and identity shifts, which students found more taxing. Participant 12 admitted that “my writing relied heavily on descriptive content, while critical reflection and analytical evaluation were limited” because they were less confident in critical analysis. Similarly, Participant 10 found the requirement for personalized reflection far more challenging than simple memorisation.

Pedagogical strategies for optimised internalisation

As summarised in Table 3, the final research question sought to identify evidence-based strategies for teachers to move feedback from the Blind and Hidden areas into the Open Area, where internalisation is most likely.

To transform the Blind Spot from a source of shock into a site of growth, teachers should shift from a judgement framework to a coaching framework. The SBI Model is particularly effective; by focusing on the specific impact of an observable behaviour (e.g., “Reading from the script made it hard for the group to see your independent thinking”), the tutor allows the student to see themselves through an objective lens without feeling attacked. Participant 10 highlighted the importance of discretion in these encounters: “I appreciated that he spoke to me in private instead of criticising me in front of the whole group, which prevented greater embarrassment.” Participant 12 further confirmed the effectiveness of a coaching approach when the tutor “pointed out weaknesses gently and provided practical examples to show how I could improve.”

To dissolve the Hidden Area, teachers must create ‘Feedback Solicitation’ loops by eliciting the ‘Student’s View’ before evaluation. Participant 3’s resistance was clearly linked to a lack of such loops: “I see no point in explaining my busy schedule to them, as I believe it would not change anything”. When solicitation occurs, tension is significantly reduced; Participant 9 reflected that “communication has helped… After each discussion about travel and studying, I explain my plans and thoughts slowly, which eases tensions over time”. This allows hidden stressors to be moved into the Open Area where the teacher can provide ‘Matched Support’.

Furthermore, the use of Gentle Guidance Interventions (GGIs), such as the ‘Assumption of Intelligence,’ can redirect behaviour without escalation. Participant 11 found that when the instructor’s tone was calm and gentle and provided detailed solutions, it fostered a receptive environment. Instead of telling a student they are wrong, asking ‘What should you be doing?’ preserves the student’s sense of autonomy. This strategy is vital for maintaining the ‘Culture of Vulnerability’ necessary for students to reveal insecurities; as Participant 7 noted, ‘Through further communication, I finally understood my core responsibilities and the purpose of the work I had completed before’.

Interpretation in light of the johari window

The findings of this study demonstrate that the Johari Window is a dynamic rather than static model in the context of medical education. The success of feedback is not measured by the accuracy of the tutor’s observation, but by the fluidity with which information can be moved across quadrants into the Open Area.

In the Open Area, the feedback loop is closed quickly because the student is already feedback literate - possessing the capacity to use information to enhance their strategies. However, the most profound transformations occur when feedback successfully navigates the Blind Spot. This transition is mediated by the ‘Credibility of the Teacher’ and the trust in the relationship. As seen with Participant 13, who moved from impatience with a strict teacher to realising their good intentions, the internalisation occurred when the student moved from Kelman’s level of identification to internalisation, where the satisfaction came from the content of the new behaviour rather than the act of conforming.

Conversely, the Hidden Area acts as a major site of pedagogical failure. The thematic analysis suggests that when a tutor ignores the student’s hidden reality, the feedback is perceived as contextually invalid. This triggers a strategic masking behaviour, where students like Participant 9 adopt conversation obedience to maintain a social relationship with the tutor while privately rejecting the feedback. This finding highlights that for internalisation to occur, the feedback provider must first shrink the Hidden Area through empathetic solicitation.

Advancing the johari window through this study

This study advances the original Johari Window theory by developing a ‘Feedback Internalisation Instrument’ that maps the model onto the developmental process of values integration.

Firstly, the study identifies emotional thresholds for each quadrant. While the original model identifies that information is hidden or unknown, this research quantifies the affective cost of uncovering that information. We propose that the Blind Spot has a high ‘Ego-Shock’ threshold, occurring because feedback here is often perceived as an attack on personal identity or character rather than just performance. Conversely, the Hidden Area is defined by a high reactance threshold, acting as a defensive surge to reassert the student’s autonomy when their undisclosed context - such as workload or personal stressors - is ignored. Tutors can use these emotional markers as diagnostic indicators: Ego-shock suggests they have hit the Blind Spot, while reactance or resentment indicates they have triggered a conflict in the Hidden Area.

Secondly, the study links the Johari Window to Kelman’s Social Influence Theory in a hierarchical manner. We suggest that each quadrant corresponds to a different depth of influence:

Thirdly, this study introduces the concept of ‘Communicative Competence’ as a dual requirement for expanding the Open Area. While previous research focused on the student’s feedback literacy,^13,14 our findings suggest that teacher feedback literacy - encompassing relational and pragmatic competencies - is equally critical. Tutors must utilise ‘Compassionate Communication’ to navigate the relational dimension of feedback. By employing GGIs like the assumption of Intelligence, tutors prevent the impossible choice between obedience and autonomy, thereby preserving the student’s sense of intelligence and competence. This moves the Johari Window from a simple communication tool to a structural framework for designing medical curricula that prioritise psychological safety and self-regulated learning.