BMJ Learning

Small group teaching

د. حسين محمد جمعة
اختصاصي الامراض الباطنة
البورد العربي
كلية طب الموصل
2010

About the author

John Goldie is a senior clinical tutor in the Section of General Practice, Division of Community Based Sciences, University of Glasgow. He has been involved in small group teaching for 15 years and has led a variety of groups including Problem Based Learning groups.

Why I wrote this module

"On starting teaching I received little training on how to teach. I found small group work to be one of the most challenging areas in teaching, particularly as I had little prior experience. My Master in Medical Education provided a theoretical basis on how to undertake small group teaching, which I then applied to my practice. I hope that by writing this module it will similarly help those who teach small groups."

Key points

The process of small group teaching can be adapted to fit all the models of teaching and is compatible with the principles of adult learning
A key aspect of learning in a group is interaction between group members
Teachers must have appropriate communication and leadership skills and a knowledge of group dynamics
Teachers must reflect not only on how effective their teaching has been, but also on how the group is developing.


Introduction
Small group teaching is increasingly used in undergraduate and postgraduate medical education. Effective small group teaching is more challenging than is often realised. One of the main challenges for teachers is that each group has its own dynamic quite independent of the individuals comprising it. The effectiveness of the teaching and learning in small groups depends on the skills of, and the strategies used by, the teacher.

What is a small group?

David Jacques, a leading expert on group teaching, suggests that more than two people interacting for longer than a few minutes constitute a group. The interaction of group members, through face to face contact, is considered a key characteristic of group learning.

Group members, however, not only interact with each other but also form relationships. As such, a group is a social organisation with roles and norms, standards of behaviour to which each member is expected to conform, and where behaviours may be influenced by factors such as hierarchy and the power of members as well as many other factor

What size should the group be?

It is generally recommended that the optimum size for a small group is between five and eight students, with twenty students being the upper limit for productive interaction. But the size of a group is often determined by factors over which teachers have little control, for example faculty requirements.

The size of the group is also dependent on the type of teaching required and the approach adopted. In situations where the group is bigger, it is important to maximise interaction by breaking the group into subgroups - for example using the syndicate format.

Notes

a .Tutorial usually means a format in which the teacher and students discuss a specific topic. It normally involves some preparation by students.
b. The terms tutorial and seminar are often used interchangeably. The main distinguishing features are the group size and the degree of individual attention students receive. In seminars it is more common for students to lead parts of the discussion - for example by giving a presentation.

c .Learning sets are groups of students that meet over a period of time. Members identify their own learning needs and meet them within the group, which may or may not be facilitated by a teacher.
d .Syndicates are a format where a large group is split into smaller groups. Each group undertakes different tasks or assignments, which are fed back in a plenary session to the whole group.

e .Group practicals are common in scientific subjects such as biochemistry. The large group is broken down into smaller units, each of which carries out a practical task - such as an experiment.


Why use small group teaching?
In recent years there has been a shift in healthcare education from a teacher centred approach, where the emphasis is on teachers and what they teach, to learner centred education where the emphasis is on the students and what and how they learn. This has largely resulted from Knowles' observations of how adults learn.

Box 1: Knowles' Principles of Adult Learning

An effective learning climate should be established. Learners should be comfortable, both physically and emotionally. They should feel "safe" to express themselves without judgment or ridicule.
They should be involved in planning (in deciding what they learn and how they learn).
They should be involved in evaluating their own learning needs.
They should be encouraged to set their own learning outcomes.

They should be encouraged to identify the resources they need and devise strategies for using them to achieve their outcomes.
They should be helped to carry out their learning plans. One of the key elements of motivation is the expectancy of success. Learners become discouraged if a task is too difficult. In addition, too much pressure without support can have an adverse effect.
Learners should be involved in evaluating their learning. They should consider not only what they learnt but also how they learnt.

Lectures are unable to meet many of these requirements. To realise the principles of adult education educators have embraced other teaching methods of which small group teaching has been the most prominent.

Small group teaching has the potential to:

Promote active involvement in learning
Enable students to learn from other group members.
Motivate students through interaction with their peers.
Activate prior knowledge through discussion and reflection - promoting deeper learning
Encourage development of "higher order" intellectual skills such as reasoning, evaluation, and problem solving


Encourage the development of interpersonal skills such as listening, questioning, and debating
Provide opportunities to explore attitudes and develop awareness of different viewpoints, which can lead to changes in attitudes
Encourage students to take responsibility for their own learning, particularly in problem based learning
Encourage the development of leadership and group skills.
Foster collaboration and cooperation, which are important skills for effective teamwork.

Think

You are asked to deliver a teaching session on "breaking bad news." You decide to use a small group format rather than the lecture format that has been used previously. Your colleagues question whether this is justified in terms of cost. How would you respond?

Group dynamics

In order to run a small group, you need to have some knowledge of group dynamics. Groups meeting over a period of time have predictable patterns of growth and development. Understanding these can help you to do the right thing at various stages of the group's development.
There are five main stages which groups go through.

There are five main stages which groups go through.

Stage 1: Dependency and Inclusion - new groups often begin relationships in a state marked by high anxiety, uncertainty, and politeness. Group members are mostly concerned with psychological safety, reduction of uncertainty, and establishment of boundaries. They tend to defer to the leader and be tentative, even defensive, with minimal work occurring.

Stage 2: Counter dependency and Fight - in this stage each member seeks to identify and define individual roles more clearly. Individuals and coalitions may have different ideas about how the group should operate as the social structure is still forming. Power struggles can arise at this stage and the full resources of the group may not be available for application to the group task.

Stage 3: Trust and Structure - communication becomes more oriented to the task and people become comfortable giving and receiving feedback. Members of the group know what to expect from each other.
Stage 4: Work - group members share information with each other and know where different kinds of knowledge and expertise lie within the group.


Stage 5: Termination - this is marked by a general awareness of an impending loss of group stability, which can create anxiety and even conflict. Consciously recognising and managing these can promote members' abilities to work effectively in subsequent groups.

By knowing about these stages, you will not become discouraged by the group's dependency on you during stage 1 or the lack of progress during stage 2. By stage 5 you should be in a position to help students gain a realistic perspective of the group's achievements.

Studies have shown that members' achievement is positively correlated to group development.9 However, many groups fail to reach, or are not kept together long enough to reach, the work stage of development. It is important that you keep groups together long enough for them to develop.

Think

What strategies might be effective in promoting group development - particularly in the early sessions?

How to run a small group

Physical resources
Students should be comfortable both physically and emotionally. Although you may not have much control over the choice of venue, it should be made as suitable as possible. The room should be at a reasonable temperature, there should be minimal interference from noise, and the room should contain the appropriate equipment. Refreshment facilities should be available - particularly if the session is to last longer than an hour. Students need regular breaks during longer sessions.

Face to face contact

It is well known that seating affects the pattern of interaction, although teachers often neglect this. Sitting in rows, for example, will inhibit interaction between students and between you and your students.

Students at the back will disengage while those at the front may feel awkward. You may similarly feel awkward being at the front and may end up dominating the group. The most effective arrangement is one that promotes face to face contact and increases interaction. A horseshoe or circle are the most effective arrangements.

Preparation

As with any type of teaching, preparation is essential. This should include reflection not only on what and how the group should learn, but also how the group is developing.
Box 2 provides a structure for planning a small group session.


Box 2: Questions to consider in planning small group sessions
If it is a new group
Who is being taught?
Who are the students, what level are they at?
What is the size of the group?
Think to yourself
How will I encourage introductions?
How will I promote group safety?

If an established group

What stage of development is this group at?
How long is the session scheduled to last?
What are the learning outcomes?
How will I get them to assess their learning needs?
What content needs to be covered?
What, if any, prior reading have they been assigned?
Think to yourself.

How will I focus the learning tasks?

What resources do I need?
How will I keep it going?
What activities will take place during the session?
How long will we spend on each activity?
How will I monitor students' participation?
What strategies will I need to promote participation?
How will I close the session?
What take home messages should I emphasise?
How will I evaluate the session?


Think
You are asked to run a one hour small group session for eight colleagues on a clinical topic. How would you plan the session?

Starting the group

Group safety
As mentioned previously safety is important, particularly in the early stages. Participants need to feel safe enough to contribute.
Ways of promoting safety and cohesion include:
Icebreakers
Establishing group rules.

Icebreakers

These are methods of encouraging introductions. They are particularly effective when the group meets for the first time. They include activities such as pairing people up and asking them to ask their neighbour for their name, where they come from, what hobbies they have, what they hope to get out of the course, and then report this back to the whole group.

It is important when using icebreakers that they are kept short and that you avoid exercises that make participants feel embarrassed.

Group rules

Establishing group rules would typically follow the icebreaker. The best approach is to get the group to "brainstorm" the list of rules, where students are invited to make suggestions without having to justify them. The rules should be clear and simple.
It is important that group rules are not "written in stone" (you should be able to change them when necessary).

The following are typical examples:

Start and finish on time
Switch off mobile phones
Don't interrupt if someone is talking
Participants should own their statements - "I think . . ." rather than "People think . . ."
Everyone has a right to express views and be heard
Debate rather than argue
Disagree, but don't put other people down
Decide on if and when to take breaks
Stick to the task


Discussions should remain confidential to the group
Undertake the tasks you agree or offer to do
While the aim is consensus, the group will work with majority decisions where needed
It's OK to ask questions - there are no stupid questions.

Defining needs

You should then discuss students' expectations of learning. It is important you ensure both individual and group needs are considered. An effective method, which allows for the blending of individual and group needs is the Nominal Group Technique, outlined in table 2.

Table 2: Steps in the Nominal Group Technique

The task is stated - what issues should be addressed?
Participants write down their ideas silently and independently
All ideas are listed in a "group round" fashion, where each student is asked the same question in turn, with clarifying questions, but no discussion

Ideas are defended by the proposer and agreements or disagreements voiced

Group members evaluate the ideas, list their top five priorities and then rank these from the highest (5 points) to the lowest (1 point)
The votes are counted and the results recorded on a flowchart
There is further discussion of the ideas and the voting pattern
The voting is repeated and the ideas are tallied and then listed in order

Even in more structured teaching situations, where the content and learning outcomes are predefined by the course designer, it is important to get students to review the expected learning outcomes and discuss their expectations.


Setting tasks
The next step is a short presentation to introduce the session and establish tasks that focus discussion on relevant issues. You may wish to prepare a case scenario in advance - in order to promote discussion.

Keeping it going - encouraging group participation

Once started it is important that the group performs its tasks and meets its learning needs. In one off sessions such as bedside teaching this is the main role of the teacher. In sessions where the group meets over a period of time you need to make sure the group is functioning and its members are contributing.3
Task maintenance requires the tutor to:
Have a clear idea of the aims
Monitor time carefully

Use a variety of strategies to encourage participation

Ensure the aims are achieved, where possible.
Group maintenance involves the tutor monitoring:
Group dynamics
Participation
Non-verbal behaviour
Conflict among group members.
To promote participation you need to possess communication and leadership skills.

Communication

Good communication skills are essential.
Listening
A good listener listens with their eyes as well as their ears. Listening to your students involves not only tuning in to the actual words that are spoken, but also how they are spoken, for example the tone of the student's voice and their body language.


Attentive listening is characterised by good eye contact, encouraging gestures such as nodding, and appropriate body language such as leaning towards the participating student. A good listener appears interested, does not interrupt, and maintains focus.

Questioning

The whole of teaching and learning, as Hamilton observed, is "shot through with the art of questioning."12 Asking the right question at the appropriate time can help3:
Show you have been listening
Arouse interest
Activate prior knowledge
Test knowledge and understanding
Make students think
Motivate

Promote new insights

Model professional thinking
Diagnose strengths and weaknesses.
To achieve these appropriate questions have to be asked. Questions can be classified along four dimensions:

Closed/Open

Closed questions are framed to require a brief, specific response - for example "Are you John Smith?" While you may often begin with closed questions they should be restricted for clarification of facts. Open questions such as "What are the options at this point?" require relatively wide ranging answers and are used to stimulate reflection and discussion.

Recall/Thought provoking

Recall questions for example "What are the symptoms of . . ." are often used in the early stages of discussion to assess knowledge and start students thinking. These should lead on to thought provoking questions, for example "How can health inequality be tackled?" which provoke students' higher order thinking, yield a greater number of responses, improve students' understanding, and result in more positive evaluations of teaching.


However, research has shown that tutors tend to mainly ask recall questions and few higher order questions. It is important for tutors to consider what key higher order questions may be required during the session and not wait for them to arise spontaneously.

Confused/Clear

Clear questions are usually brief, direct, and appropriate to the context of what the student said. Confused questions are often double questions where the student is unclear as to which part of the question to answer, for example: "I wasn't sure if you were suggesting a link between health and prosperity. You linked health to healthcare provision. You seemed to be suggesting a link between healthcare provision and prosperity. What do you think?"

Encouraging/Threatening

You want your students to think and contribute. Be encouraging, but this does not mean you should not be challenging or able to confront them intellectually. To prevent coming across as threatening be aware of your choice of words and the tone of your voice.

Some useful tips for good questioning include:

Make your questions clear. Avoid double questions
Start with closed questions but restrict them to clarification of facts. Ask more open questions in all other circumstances
Use recall questions in the early stages of discussion. Plan for the higher order questions that may be required
Be encouraging, but don't be afraid to challenge or confront
Allow adequate thinking time. Don't ask a question and immediately answer it if no one responds.

When a student asks a question use a counter question, for example "Can anyone else answer that?"
If you receive a poor answer follow it with a simpler one as the original question may have been pitched at too high a level
Avoid always asking questions of students who are the brightest or most likeable
As the group develops, questions should be increasingly asked by the students.

Explaining

A learner centred approach can be adopted when providing explanations. This can be achieved by:
Checking students' understanding at the start, monitoring understanding as you proceed, and checking it again at the end
Giving examples of practice relevant to the topic and/or referring to students' prior experiences.


Giving your explanation in small chunks, summarising periodically, and signposting when you move on to the next part of the explanation
Presenting information using visual means
Actively engaging students by asking questions
Using technical language appropriate to the students' level and avoiding jargon
Summarising at the end, emphasising key points, or asking a student to summarise.

Giving feedback

Most students want and need feedback.
It motivates, encourages reflection, increases confidence, and can change behaviour. Feedback should be an interactive process.

Ideally all group members should be involved in providing feedback. Some points to consider are:
It must be given at the right time and in the right way It should address the gap between what happened and what could or should have happened
It works best when requested or at least anticipated and is most effective when the receiver respects the provider
It should be specific and based on observation and evidence.

In keeping with the learner centred approach, a useful method is the Agenda led, Outcome based analysis.15 In this process you:
Encourage the student to reflect on what happened
Help them identify their learning needs
Encourage self assessment and problem solving
Use descriptive feedback - criticise behaviour not the person
Make offers and suggestions - don't be directive
Provide balanced feedback
Ask other group members to contribute
End with an action plan, if appropriate.


Group leadership
Knowing what to do is essential in establishing and maintaining a positive group climate. The skills or behaviours necessary have to be practised. The following skills may be helpful:
Glancing round the group
By scanning the group, both when you are talking and when students are contributing, you can encourage students to copy this behaviour. This can encourage the whole group to give the speaker more attention.

Looking for signals

Again by glancing round the group when a student is contributing you may find yourself picking up cues from other students. Often the cues are no more than a deep intake of breath or a puzzled frown. As the particular contribution ends, you will be in a better position to draw in some of the less vocal students who may prefer to take a more passive role in the group. You will also be more aware of the group climate and may even give the group a better sense of its own identity.

Using non-verbal communication

Sometimes when it may be difficult to interrupt a discussion without sounding critical or punitive a non-verbal intervention can be very effective. This might consist of catching a student's eye and giving them an encouraging smile or by gestures such as extending a palm to suggest "Would you like to come in now?" or using two hands to indicate "What does everyone else think?"

Bringing in and shutting out

To encourage students to talk you may need to invite individual students into the discussion, either verbally or non-verbally. As mentioned above, you may pick up significant non-verbal signals that a reluctant student wants to speak, for example when they silently smile or frown at what's been said. On such occasions you might say "What are you thinking ?"

On the other hand you may want to restrain someone who tries to dominate the group by constantly talking or interrupting. This has to be done honestly and supportively, for example "Could you just hold it there? It would be interesting to know how the others respond to that." Other strategies include asking the dominant student to be the note taker or even to lead the group.

Reflecting and deflecting questions

When students ask questions such as "Can you tell us what you know about . . . ?" or "What should the answer be?" you may be tempted to comply with their desire to set you up as an expert. A simple way out of this situation is to turn the question back on the student, for example ask: "Well, what do you think?" This can be justified on the grounds that the student probably has an idea of the answer anyway or they would not have asked the question.

An alternative strategy is to deflect the question by inviting other students to provide the answer, for example: "Does anyone have any ideas?" However, there are occasions where the teacher is the only person in the group who might know the answer or where a refusal to answer could slow down proceedings. In these situations the teacher may need to provide an explanation.


Redirecting
Sometimes you may wish to change direction. It may not be easy to decide whether students would be glad of a change in direction or to continue along the same line of discussion. A safe way of approaching this problem is ask the group "Are you ready now to tackle . . . ?" It may be even more valuable to check the process as well as content: "Could we stop at this point and check whether we're going about this the right way?"

Making the group smaller

When discussion breaks down another useful strategy is to break the group into smaller units to promote interaction, change pace, and maintain interest. Some of the commonly used techniques are:

Group round

In this situation you go around the group and ask everyone to contribute. The first contributor can decide the direction round the group that students will be questioned or it can be in random order. In a large group students may run out of things to say towards the end of the round. In these circumstances it is appropriate to allow people to pass if they have nothing to add.

Brainstorming

This useful technique can be used to help students activate their prior knowledge or promote creative thinking. All ideas are welcomed. Ideas can be recorded on sheets of paper displayed around the room. Analysis, discussion, and evaluation of ideas should only take place after the generation of new ideas has finished.

Buzz groups

Students are put in pairs or in groups of three and given a task or discussion topic, usually the same one. A time limit must be specified. Discussion within the groups may be sufficient without any need for reporting back. Buzz groups help students to express difficulties they would have been unwilling to reveal to the whole class.

Role play

Role play is any speaking activity when you either put yourself into somebody else's shoes, or when you stay in your own shoes but put yourself into an imaginary situation. It is a particularly useful technique when attitudes are being explored or the aim of teaching is to develop students' abilities to relate to other people (box 3).

Box 3 Benefits of role play (after Spencer)

Allows students to express hidden or difficult feelings
Enables the discussion of challenging issues, such as abortion
Helps develop empathy and understanding
Allows students to practise a range of behaviours and responses
Helps shape students' attitudes
Motivates the group by being relevant to real life situations
Can be fun


Many students and teachers dislike role play. This is often due to fear based on a previous negative experience. There are a number of things to consider when using it:
Be clear why it is being used
Be open about the fact it might not work - this takes the pressure off individuals to "perform well"

Assign roles - make sure everyone is clear as to what they are supposed to do

Allow appropriate time for students to think through their role
Specify observational tasks to other students
Allow sufficient time, but don't let it run on if it is not working
Give constructive feedback
Make sure there is time for debriefing and discussion
Consider what can be learnt if it doesn't work.

Think

How would you deal with:
An unresponsive group?
A dominant group member?
A reticent group member?

Promoting critical thinking

One of the most important skills for healthcare professionals is the ability to think critically. Some educators are of the opinion that this develops simply by participating in higher education and question whether it can be taught.


Studies have shown that you can help your students develop critical thinking strategies. Brookfield's rules of thumb for facilitating critical thinking emphasises that there is no standard approach. He makes a number of recommendations.

Brookfield's strategies for facilitators of critical thinking:

Affirm students' self worth
Listen attentively
Show support
Reflect and mirror students' ideas and actions
Motivate students
Regularly evaluate the process
Help students create social networks with like minded learners
Be critical educators
Raise awareness of how to learn to be critical thinkers
Be role models for critical thinking.

Small group teaching is particularly effective for promoting critical thinking, as many of the strategies for fostering critical thinking are integral to the small group teaching process. To help your students you can at first talk them through how you would think in a particular situation. You should then encourage them, in similar situations, to talk through their thought processes, provide feedback, and invite feedback from the other group members.

It is important you take risks when helping students develop their critical thinking skills, for example by recognising opportunistic teaching moments and acting on them even when it involves areas you did not plan at the outset.

Evaluation

This involves not only helping your students reflect on what and how they learnt, but reflecting on how effective your teaching has been. It is also important to reflect on how the group is developing.
Methods of evaluation include:
Questionnaires - a simple format is best:
What went well
List three things you got out of the session
What didn't go as well
Suggestions for improving the session


Get students to discuss in pairs for a few minutes what they got out of the session and how this was achieved, then do a group round
At the beginning of the next session devote five minutes to a critique of the previous meeting
Ask a colleague, with the group's permission, to observe a session and provide feedback on what worked well and what didn't work as well.

Video or audiotaping allows you and your students to contemplate behaviours. To be productive there must be a shared commitment by the group to act on any feedback given. It must not be used too early in a group's development or too late for it to be of benefit.

Learning bite

Remember that an essential feature of small group teaching is that the members interact and form relationships with each other as well as with the tutor. Small group learning is not just student/teacher interaction in a group of students, it is student/student interaction guided by a "teacher."