amee guide 08 learning in small group

7/22/2019 AMEE Guide 08 Learning in Small Group

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8Learning in Small Groups

Joy Crobsy

AMEE Guide


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Assessment of Clinical Competence Using the Objective Structured Long Examination Record (OSLER)

Learning in Small Groups

AMEE Medical Education Guide No 8

This guide was first published in Medical Teacher (1997) 19: 189-202.

Notes on contributorJoy Crosby, Curriculum Development, University of Dundee, Ninewells Hospital and Medical School, Dundee DD19SY, Scotland, UK.

Joy Crosby is Curriculum Facilitator at Dundee Medical School. She has a broad interest in curriculum development inmedical education and a specific interest in teaching and learning. An expertise in small group work has been developedin the Centre for Medical Education, Dundee, and utilised in the implementation of the new Dundee Medical UndergraduateCurriculum.

AcknowledgementThe author wishes to thank Neil Stamper for assistance in the preparation of this article.

Guide Series Editor: Pat Lilley

Desktop Publishing: Lynn Bell

AMEE 1997

ISBN: 1-903934-09-5

Copies of this and other Occasional Papers, Education Guides and BEME Guides are available from:AMEE, Tay Park House, 484 Perth Road, Dundee DD2 1LR, Scotland, UKTel: +44 (0)1382 631953 Fax: +44 (0)1382 645748 Email: [email protected] Website: http:\\www.amee.org


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ContentsPage

Introduction .. .. .. .. .. .. .. .. 1

What is small-group learning? .. .. .. .. .. .. 2

Active participation .. .. .. .. .. .. .. 2

A specific task .. .. .. .. .. .. .. 2

Reflection .. .. .. .. .. .. .. .. 2

Why is learning in small groups important? .. .. .. .. .. 3

The benefits of small-group learning .. .. .. .. .. .. 3

Actively learn .. .. .. .. .. .. .. 3

Encourages self-motivation .. .. .. .. .. .. 4

Allows application and development of ideas .. .. .. .. .. 4

Promotes deep learning .. .. .. .. .. .. .. 4

Promotes an adult style of learning .. .. .. .. .. .. 5

Develops transferable skills .. .. .. .. .. .. 5

Perceived problems of learning in small groups .. .. .. .. .. 6

Students do not like small-group work .. .. .. .. .. .. 6Staff do not know how to teach in small groups.. .. .. .. .. .. 7

We do not have enough teachers for small-group work .. .. .. .. 6

There are too few rooms.. .. .. .. .. .. .. 8

It is a waste of time students do not learn anything .. .. .. .. .. 8

Some small-group methods .. .. .. .. .. .. 8

Tutorial .. .. .. .. .. .. .. .. 9

Seminar .. .. .. .. .. .. .. .. 10

Snowballing .. .. .. .. .. .. .. 10

Free-discussion group .. .. .. .. .. .. .. 11

Problem-based learning .. .. .. .. .. .. .. 12

Brainstorming .. .. .. .. .. .. .. 13

Role play .. .. .. .. .. .. .. .. 14

Games and simulations .. .. .. .. .. .. .. 15

Clinical teaching .. .. .. .. .. .. .. 16

More techniques .. .. .. .. .. .. .. 17

Checklists for effective small-group work .. .. .. .. .. 17


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Prior to the small group activity .. .. .. .. .. .. 18

Consider the objectives of the session .. .. .. .. .. .. 18

Determine your available physical and manpower resources .. .. .. .. 18

Determine the group size and group membership .. .. .. .. .. 20

Ensure that the staff are prepared for the session .. .. .. .. .. 21

Select the most appropriate small-group method to fulfil the objectives .. .. .. 21

Develop stimulus material .. .. .. .. .. .. 22

Inform students about course objectives and how small-group work fits in .. .. .. 23

During the Small Group Activity .. .. .. .. .. .. 23

Allow adequate introductions - use breakers if necessary .. .. .. .. 23

Ensure that the students understand what to do .. .. .. .. .. 24

Facilitate learning .. .. .. .. .. .. .. 25

Debrief the group on the activity .. .. .. .. .. .. 27

After the Small Group Activity .. .. .. .. .. .. 28

Evaluate the success of the session .. .. .. .. .. .. 28

Reflect on the experience .. .. .. .. .. .. 29

Conclusion .. .. .. .. .. .. .. .. 30

References .. .. .. .. .. .. .. .. 31


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IntroductionThere is a recent trend towards small-group work inundergraduate medical courses. Current understanding ofeducational strategies supports the use of small groups asan effective method of learning. Small-group work recognises

a movement towards learner-centred, problem-based andself-directed learning. The exploration of knowledge, learningthrough curiosity, the critical evaluation of evidence and acapacity for self-education are all fostered in small-groupinteractions.

This article explores the rational arguments that support themovement towards small-group learning, the many benefits

from small-group activities and the many types of small groupmethods. Small groups interact in a variety of ways and theteacher has an important role. Barriers, more often perceivedthan real, may impede the adoption of small-group teaching.

Practical guidance is offered on why to adopt small-groupwork and how to do it effectively. The teacher is providedwith a framework for running small-group sessions and isgiven three simple checklists to consider before, during andafter the small-group activity.

Keywords education, teaching, small groups, facilitator

What is small-group learning?The term small-group learning can be misleading, as smallimplies no definite number. The literature is equivocal on thenumber of students that constitutes an effective small group.Small-group teaching depends more on the featuresdisplayed by that group than on the number in it. Usually, butnot always, meaningful interaction occurs more readily withfewer people. You may have your own preference. To you,effective groups may have less than 10 participants. However,some groups may work effectively with a larger number ofparticipants: some may be ineffective with a smaller number.

What matters is that the group shows three characteristics:active participation, a specific task and reflection.

Active participationThe most important feature of small-group work is thatinteraction should take place among allpresent. Levels ofparticipation may vary among members. It is important thatthere is some participation by all members.

A significant aspect of group work is the response ofparticipants to other members in the group. Responses mayoccur in a number of ways. If face to face, effective discussiondepends on interaction. This is much easier to achieve arounda small table or in an open circle rather than with the studentssitting in rows or around long tables. Ensure that members ofa group can see each other, to pick up visual and verbalcues from each other.

Group work can also be achieved through teleconference ortelephone. If the link is sound only, visual cues becomeinsignificant. Reliance is placed on audio response andinteraction.

A specific taskThe group must have a clearly defined task. Group workshould be focused. Unclear objectives can cause frustration- for the teacher (Tiberius, 1990) as well as the students. Ifstudents are confused about the objectives, the group mayappear unresponsive. The task and objectives should beclearly understood by all members of the group, allowing themto focus on that task.

ReflectionIn small-group learning, it is important to learn from anexperience and to modify behaviour accordingly. Deeplearning is a key feature of small-group work: reflection is akey feature of deep learning. Reflection may be explicitlyscheduled into a session. Alternatively, a session may bededicated to the reflection process. The importance ofreflection was highlighted by Kolb (1984) in his experientiallearning cycle. Reflection is generally counted an importantaspect of turning experiences into learning (Boud, Keogh andWalker, 1995).

These three characteristics of small-group work may be moreobviously displayed in groups that are small in numbers.However, a skilled facilitator may be able to engender someof these qualities in larger groups.


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Why is learning in small groups important?Small-group work has always been important in medicaleducation. Its prominence has recently increased in highereducation for several reasons.

Understanding of the key features of small-group work hasincreased. These key features include active participation(Garland, 1994; Tribe, 1994; Walton, 1983), self-direction andthe promotion of deep learning. Surface learning is superficiallearning, leading to the regurgitation of facts and figures: it ispassive and shallow, with the knowledge tending not to beretained by the student (Rowntree, 1985). Deep learning goesbeyond this, with questioning and evaluation of what is beinglearnt.

In addition to being an effective method of learning, small-group work offers experience of working in a group and helps

students acquire group skills. Such skills are an importantfeature for general employment (Garland, 1994; Tribe, 1994).Gaining an understanding of the difficulties that can arise ingroups and developing self-confidence through expressing

and defending ones ideas (Reynolds, 1994; Walton, 1983)are all skills developed through group work. Group skills arecrucial in the medical profession, where working in a groupor team is an important aspect of holistic health care. Groupskills also include the ability to communicate effectively, theprioritising of tasks, the management of time and the exerciseof interpersonal skills. Frequently, students may be expectedto acquire these attributes without being given any designatedopportunities to practise or demonstrate them. Small-groupwork gives students such opportunities.

The benefits of small-group learningSmall group teaching has many advantages to offer thelearner.

Actively learnOnly an individual truly knows what understanding he or shehas of a topic. Learning is fundamentally concerned with whatan individual does not understand. In learning, a lack ofunderstanding is identified, and converted to understanding.It is sometimes difficult, in isolation, to work out what oneunderstands, doesnt understand and needs to understand.Norman and Schmidt (1992) consider that learning shouldbe an active, constructive mental activity that enables studentsto build from what they already understand. How should astudent assess that understanding or lack of understanding?Group discussion activates previously acquiredunderstanding, helping identify any deficits and facilitatingnew comprehensions (Barrows and Tamblyn, 1980; Schmidt,Dauphinee and Patel, 1987).

Group work maximises the opportunity for students to useany prior learning, to identify their own learning deficits andto develop understanding of material. Small-group work allowsstudents to self-direct their own learning. It encouragesreflection upon and control of learning activities anddevelopment of self-regulatory skills conducive to lifelonglearning (Glaser, 1991; Barrows and Tamblyn, 1980).

Encourages self-motivationAn individual learns more when enjoyably involved (Reynolds,1994). Small-group work increases a persons involvement.

Active involvement motivates people to learn: it also allowsthem to learn more effectively (Tiberius, 1990). Students andstaff both report, as a result of working in small groups,increased short-term motivation and satisfaction with learning(Neame, 1982; Schwartz, 1991; Norman and Schmidt, 1992;Walton and Matthews, 1989).

Allows application and development of ideasAssociated with involvement is the opportunity to apply ideasand to consider potential outcomes. A functioning group willhelp clarify concepts and theories. Discussion, acceptanceand seeing connections within the group may enhance amembers intellectual understanding of an issue. A didacticlecture seldom allows students to test out hypotheses or toexplore different possibilities.

Promotes deep learningDeep learning is better than surface learning (Jacques, 1986;Entwistle, Thompson and Tait, 1992; Rowntree, 1985). Forsurface learning - learning only facts - there is little differencebetween using a lecture or a small-group method (McKeachie,1986). Indeed, lectures may even be superior (Rudduck,1978; Abercrombie, 1971). However, in a group, membersare more likely to exhibit a deep-learning approach (Coles,1985; Newble and Clarke, 1986). Students understand andmake personal sense of the material - rather than justmemorising and reproducing (Entwistle, Thompson and Tait,

1992; Walton, 1983).


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Small-group work is better than a lecture for higher-orderactivities - eg, analysis, evaluation and synthesis (McKeachie,1986). This may reflect increased motivation in small groups.Active participation, with face-to-face contact, may ensurethat a member seeks to understand at a deeper level.

Promotes an adult style of learningIt is important that professionals accept personal responsibilityfor their own progress and direction of learning. Intellectualindependence and maturity can be developed throughinteraction with other students (Walton, 1983). Valueclarification, attitudinal change, being acknowledged as anindividual, development of self-esteem, increase in self-confidence all these can be achieved in group work.Questioning authority and using feedback from mistakes willalso develop the individuals professional competence(Entwistle, Thompson and Tait 1992).

On entering higher education, many students may appearimmature and irresponsible. Yet they are expected, aftergraduating, to take on adult responsibilities. Knowles (1984)coined the term andragogy for the development of an adultlearning style. This can be encouraged by adopting small-group teaching methods. Ideally, students should eventuallytake responsibility, as in postgraduate education, for their ownlearning. Teachers may claim the immaturity of studentsimpedes approaches that are student centred. However, byfailing to recognise the importance of student responsibility,teachers may be fundamentally failing students.

Responsibility for ones learning is difficult to achieve in atotally didactic setting. Students should be given opportunitiesfor group learning, in conjunction with exposure to otherlearning strategies.

Develops transferable skillsTransferable skills are of increasing importance foremployees. Increasingly, they are seen as important attributesin health professionals. Transferable skills, common to themanagement of all patients, may include: leadership,teamwork, organisation, giving support, prioritising and settingtasks, encouragement to others, problem solving, monitoringclimate, managing time. Such competences are best fostered,not by direct teaching to transmit information, but by teachingto encourage specific kinds of cognitive activity (Glaser, 1991).

Teamwork Working in a group provides mutual support,laying the foundations for future teamwork (Colditz, 1980;Walton, 1983). Students can observe the effect they haveon other members of the group (Walton, 1983). Theseexperiences may influence future behaviour andstrategies adopted with professional members of a team.Multi professional aspects of health care require teamworking. Ideally, in undergraduate training, studentsshould be exposed to shared small-group learningsessions with multi professional team members.

Problem-solving abilities Analysing, evaluat ingevidence, logical reasoning and synthesising isencouraged in some forms of small-group work. It is hardto achieve such problem solving in the didactic lecturesetting.

Promotes an adult style of learningIt is important that professionals accept personal responsibilityfor their own progress and direction of learning. Intellectualindependence and maturity can be developed throughinteraction with other students (Walton, 1983). Valueclarification, attitudinal change, being acknowledged as anindividual, development of self-esteem, increase in self-confidence all these can be achieved in group work.Questioning authority and using feedback from mistakes willalso develop the individuals professional competence(Entwistle, Thompson and Tait 1992).

On entering higher education, many students may appearimmature and irresponsible. Yet they are expected, aftergraduating, to take on adult responsibilities. Knowles (1984)coined the term andragogy for the development of an adultlearning style. This can be encouraged by adopting small-group teaching methods. Ideally, students should eventuallytake responsibility, as in postgraduate education, for their ownlearning. Teachers may claim the immaturity of studentsimpedes approaches that are student centred. However, byfailing to recognise the importance of student responsibility,teachers may be fundamentally failing students.

Responsibility for ones learning is difficult to achieve in atotally didactic setting. Students should be given opportunitiesfor group learning, in conjunction with exposure to otherlearning strategies.

Develops transferable skillsTransferable skills are of increasing importance foremployees. Increasingly, they are seen as important attributesin health professionals. Transferable skills, common to themanagement of all patients, may include: leadership,teamwork, organisation, giving support, prioritising and settingtasks, encouragement to others, problem solving, monitoringclimate, managing time. Such competences are best fostered,not by direct teaching to transmit information, but by teachingto encourage specific kinds of cognitive activity (Glaser, 1991).

Teamwork Working in a group provides mutual support,laying the foundations for future teamwork (Colditz, 1980;Walton, 1983). Students can observe the effect they haveon other members of the group (Walton, 1983). Theseexperiences may influence future behaviour andstrategies adopted with professional members of a team.Multi professional aspects of health care require teamworking. Ideally, in undergraduate training, studentsshould be exposed to shared small-group learningsessions with multi professional team members.


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Problem-solving abilities Analysing, evaluatingevidence, logical reasoning and synthesising isencouraged in some forms of small-group work. It is hardto achieve such problem solving in the didactic lecturesetting.

Communication skills A small group encourages:

explaining, listening, discussing, questioning, presentingand defending a position, giving feedback (Entwistle,Thompson and Tait, 1992). This opportunity to express

Perceived problems of learning in small groups

oneself and listen to colleagues will increasecommunication skills and confidence in public speaking(Walton, 1983).

Collaborative learning One of the most frequently citeddifferences between school education and the educationof adults is the collaborative element (Brookfield, 1986).

Small-group work allows collaboration and co-operationto be expressed and developed - not only among studentsbut also between staff and students.

The introduction of small-group work into a curriculum isfrequently resisted. Various arguments are used.

Students do not like small-group workWhen small-group work is first introduced, students mayexpress dissatisfaction. Though demoralising for courseorganisers or curriculum developers, initial dissatisfaction withsmall-group work may be expected and is natural.

Self-learning shares many features with small-group work.Rae (1983) suggests five main barriers to self learning:perceptual, cultural, emotional-motivational, intellectual andenvironmental.

Perceptual The student may not perceive the value ofsmall-group work. It is difficult to value something youhave not yet experienced. These factors may influenceinitial views on small-group work.

Cultural Students may be used to being told what tolearn and how to learn it. They may have been taught in ahighly didactic fashion. Deviation from this familiar method,irrespective of how effective that deviation may be, cancause the students concern. To compound this potentialproblem, the more able or vocal students may attempt tosolve all the problems and this situation may be readily

accepted by their less able peers (Walton, 1983). Emotional-motivational In small-group teaching, the

student takes responsibility for his or her own learning.This change in emphasis can be painful and thus resisted.Weaker students may be dominated or discouraged bythose who are more confident and articulate (Walton,1983).

Intellectual Students may not appreciate that learningis ongoing. Previously, emphasis may have been placedon passing assessments rather than on deep learning.The assessment method should be changed to reflect

some of the key features and objectives of small-groupwork otherwise this barrier may persist.

Environmental The students environment maydiscourage the adoption of some ways of learning.Teachers may inadvertently stress the importance of

lectures and minimise the role of small groups. Studentswill quickly detect and adopt such attitudes.

Students will not explicitly articulate these five barriers. Theywill just report dissatisfaction. Try not to overreact againstany initial negative feedback from students. Give the small-group method time to evolve. Ensure that an appropriate peerreview is operational, to confirm or challenge studentfeedback. If information is sought, complaints will usually beequally matched by compliments.

Staff do not know how to teach in smallgroupsTeachers may lack the skills necessary for running smallgroup sessions. This is frequently seen as more of a problemby course or curriculum organisers than by staff themselves.

Frequently, the teacher desires to be seen as the font of allknowledge. A facilitator who is a content expert mayinadvertently adopt a didactic style, even with the smallernumber of students. Staff development programmes may helpsome teachers, but these are traditionally poorly attended inmedical schools. Those that do attend are usually theenthusiasts. Exposing key members of faculty to examplesof small-group learning can be advantageous. For the bestresults, visit institutions that already have established small-group methods.

For effective staff development in small-group methods,strong leaders must stipulate attendance at staff developmentsessions. Without such leadership, the system may have tofail before the teacher takes remedial action. Often, thatremedial action is not taken and the educational strategy ismerely abandoned. This is unfortunate but, until a teacherperceives that a problem exists, personal development willbe minimal.


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We do not have enough teachers for small-group workStaff shortage may be a real issue generated by the type ofsmall-group method chosen or may be a misconception.Method and timetabling both have a significant impact. Forexample, it may be very difficult to timetable a whole years

students to participate simultaneously in small-groupsessions.

Des Marchais et al (1992) suggest that moving from atraditional curriculum to one based mainly on small-groupwork, (actually problem-based learning), increased theteaching commitment by 30%. Problem-based learning is onlyone of many possible small-group methods available. A keyfeature of many small-group methods is a component of self-directed independent study by students. The increase in staffcommitment is often considered greater than is actuallyevident.

In attempting to find the required number of facilitators, themedical faculty may face a severe initial strain. To ensurethat small-group work is adequately resourced, identify allhigher-education funded posts and maximise the use of theseresources. The importance of the teachers time may be putin perspective if the learning received is more effective, anda greater cohesion, collaboration and dedication to teachingis evident (Des Marchais et al, 1992).

There are too few roomsSpace is frequently a contentious issue. Creativity is usuallythe best solution. Students, if actively engaged in any activity,are seldom easy to distract. Students may complain of quietlibraries but seldom of noisy libraries. Look carefully at thetimetabling of sessions. Use that redundant space at the front

of a lecture theatre. Try that area no one seems to usebecause of its open access. Do not be afraid to experiment -students are resilient.

It is a waste of time students do not learnanythingThere is still a belief that to teach a topic is to fulfil your roleas a teacher. It may take longer to cover a topic in small-group work than in lectures. However, what really matters isif, and how, the students have learnt the material. In the lecture

setting, there is a danger of students only learning materialin a superficial and unquestioning manner. There is aseductive security for a teacher, who knows that he or shehas imparted the relevant content in a lecture format. Acomplaint may be that They [students] should know that,because I gave them a lecture on the topic. To teach doesnot mean to learn. Scheduled whole group sessions may bemore productively used in clarifying what requires to be learntand by giving feedback on learning rather than byencouraging student note-taking of a lecture that may beadequately covered in a book or a handout.

Some small-group methodsA variety of methods can be used with small groups. Here,we will focus on: tutorial, seminar, snowballing, free-discussion group, problem-based learning, brainstorming, roleplay, games and simulations, clinical teaching. Some of thesemethods are in common use. Others, in less frequent use,indicate the range and potential of small-group methods.

TutorialTutorials let students critically probe the subject matter. Theyallow students to clarify and expand on material (Tiberius,1990). They let teachers check the progress of, encourageand guide students (Kowalski, 1989).

In a tutorial, the group discusses material already covered orpreviously assigned. The teacher can assign questions forstudents to consider, or can ask students to read a specificpassage. Tutorials may discuss topics covered earlier inlectures (Entwistle, Thompson and Tait 1992). The following

examples are taken from a tutorial on thyroid disease(Paterson, 1996).

A 20-year-old girl comes to you. She complains of nervousness,heat intolerance and has a goitre and a tachycardia. However,your partner, who has been seeing her, feels that thyrotoxicosis isextremely unlikely in view of a history of a one-stone increase inweight over the past year. Do you agree? If so, what is yourdiagnosis? How would you confirm the diagnosis biochemically?

A 26-year-old clerkess complains of having had a goitre for sixmonths, a tight feeling in the neck and increasing nervousness.On examination, she has a moderate-sized goitre; hands are hotand moist; pulse is 96. The diagnosis is thought to be thyrotoxicosis.She is started on carbimazole 10 mg qid. Two months later she isno better. Why did she not respond to carbimazole?

The student has a responsibility to prepare for the sessionand to determine which aspects require clarification. Theteacher should focus entirely on work prepared by the student(Jacques, 1985). A student may be asked, or may volunteer,to answer a pre-set question or to ask their own question onthe material received and read. After answering a pre-setquestion, the student may generate further questions. Student

questions should dictate the session. Students should beencouraged to ask questions that they feel are important totheir learning. Tutorials should never be converted into minilectures. Try asking other students to answer some of the


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queries. Some students will be happy to do this, usually usingterms their peers will understand. If a students response isnot accurate, try to correct this in a way that does notdiscourage that student from further participation.

For tutorials to work, students must take responsibility forpreparing material. If some group members do not, this canbe very frustrating for the teacher and other members of thegroup. Take care not to focus only on issues raised by studentswho have not prepared for the session. Sometimes it may bedifficult to distinguish an unprepared student from a studentwho prepared but found the material difficult.

SeminarThe seminar promotes research ability, presentation skillsand critical discussion. The teacher negotiates with studentsa piece of work for the students to present. Ideally, the group

collaboratively decides on the nature of the work forpresentation and discussion (Steffens, 1989).

The task may be assigned at the beginning of a session, withtime allowed for the generation of material during that session.More frequently, there are days or weeks between receivingthe task and making the presentation. The level of the taskwill determine the time needed for preparation. If the seminaris in a self-contained session, resource material is often madeavailable.

All students prepare the material, then it is presented to the

group by one or more students. Students should beencouraged to discuss, to analyse and to evaluate criticallythe material presented to them. During the session, theteacher may also probe the students understanding of thematerial presented.

Preparing for a presentation is one of the most effective waysto learn (Raaheim, 1991). Tiberius (1990) suggests thefollowing guidelines for the presentation session.

The presentations should only take a quarter to a half ofthe total time available.

All students should prepare, not just the presenter.

Adequate time must be allowed for the group to givefeedback. That feedback should be a substantial part, ifnot the majority, of the session.

SnowballingSnowballing allows clarification of ideas and values. It isespecially useful for students and the teacher to determinethe level of the students development and understanding.

In snowballing, the teacherdivides the group into pairs. The

students can select their own pairing. The teacher assigns toall pairs of students prepared stimulus material on a topic orissue. This stimulus material may be verbal or, as below (Ker,1996), offered as a written prompt.

Alan, aged 34, had not been to see his GP for 10 years. He worksin Stirling as an accountant and spends his weekends with hisgirlfriend in Aberdeen.

Recently he has had a gnawing recurrent pain in his abdomen.This wakens him at night but is relieved by eating. He smokes 30cigarettes a day and drinks an average of 2 bottles of wine a week.He used some of his mums aluminium hydroxide mixture. It gave

him some relief, but the pain has not gone away.

What questions would you ask, and why?

All pairs of students receive the same stimulus material. Thepairs discuss this topic or issue. The complexity of the topic,and the time available, determines the time allocated for thisstage of the session. Each pair then joins with another pair(four-person group) to compare and contrast differences intheir understanding. That group of four may then combinesimilarly with another group of four. The process is continueduntil the whole group meets to finalise deliberations in a

plenary session. The teacher should facilitate the final groupdiscussion.

Snowballing allows students to exchange views and ideas ina very direct manner. It generates ideas that are wellintegrated (Jacques, 1986) and will result in a lively finalwhole-group discussion. The initial interactions between twostudents are non-threatening. Their discussion as a pair willgive them confidence to discuss with another pair. Coveringthe topic with other members of the group allows further ideasto be expressed and the introduction of new ideas or views.

Free-discussion groupIntended to foster interaction and exploration of values andfeelings, the teacher introduces stimulus material which thefree-discussion group discusses. That material may be givenout prior to, or during, the session. The following (Preece,1996) is an example of stimulus material.

A family practitioner rings up about a 40-year-old woman. Some13 years before, she had an eye removed for malignant melanoma.There had been no further problems until two years ago, when

she had a deposit of melanoma in the right ovary. This was removedsurgically, without any evidence of other metastases or recurrence.She has recently developed neck pain. X-rays of the neck haveshown degenerative tissue to which the neck pain is attributed. Achest X-ray done at the same time, with X-rays of the cervicalspine, has shown that she has lung metastases. These areasymptomatic. There is no curative therapy, and no indication forpalliative radiotherapy, given her lack of symptoms.

Do you tell the patient (who is highly anxious and already somewhatpreoccupied with her health), or do you leave her in blissfulignorance? Discuss.

The stimulus material may take any form, eg: a brief written

scenario, data, a video clip. It may be controversial orsensitive, eg, on abortion or euthanasia. It may challengecognitive understanding, eg, the mechanisms or actions of


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drugs. Before the session, consider how long it will take tointroduce the stimulus material, to discuss the topic and tosummarise the learning that has taken place.

Once the teacher has introduced the material, group membersdiscuss it. The teacher should facilitate that discussion, whichshould range freely within the topic area. The teacher canfacilitate by asking specific and relevant questions. Finally ,the teacher should summarise the discussion. Especially if acontentious issue is discussed, there need be no clearresolution.

Problem-based learningProblem-based learning follows a simple cycle. The facilitatoryrole of the teacher varies with each stage of this cycle.

In medical schools, problem-based learning is relatively new.

The teacher must ensure that all group members know thestages of the problem-based cycle. The teacher must alsoensure that clear objectives for the small-group work aredefined and understood by all group members. Problem-based learning may be described in a dedicated introductorysession or seminar. Although several problem-based cycleshave been described, five important stages can beconsidered: first meeting, introduction of the problem, self-directed study, feedback session, evaluation session.

First meeting the group gets together for the first timeand sets the scene.

Introduction of the problem Also known as problemsynthesis, in this first stage, the teacher introduces aproblem to the group. Students should not see the problemuntil this stage. The teacher is responsible for generatinga problem and making it available to the students. Thatproblem should be prepared in advance. The followingexample comes from Boston, USA (Glick and Armstrong,1996, page 26).

Mr Royce James, a 24-year-old man with an interest in Easternphilosophy, took substantial doses of a psychoactive drug whilstseated in the lotus position. In the morning, he was found still in

the lotus position on the wooden floor, his head slumped downupon his chest, breathing slowly, unarousable.

In the emergency room of a nearby hospital, a limited neurologicalexamination revealed a young man with long hair and a sallowcomplexion. His pupils were reactive, his knee jerks 2+ symmetric,and plantar responses absent. Over a few hours he graduallyregained full consciousness, and then complained that his legsfelt heavy and he was having trouble moving them. He denied anypast general medical or neurological problem.

The students then establish the learning needs raised by theproblem. This is a key part of the learning. The students will

identify key deficits in their understanding of the problem. Allgroup members should find out more about all the learningneeds identified. The teacher should help group members

identify these learning needs. If one group member exhibitsan interest in specific learning needs, he or she may be askedto report back to the group. Generally, students will identifyall the relevant learning needs. If necessary, the teachershould facilitate the identification of important learning needsthat have not been identified by the students. One study foundthat groups identified relevant learning needs that faculty hadnot identified. Once informed of these, faculty agreed thatthe issues were relevant. (Dolamans et al, 1993).

Self-directed study After identifying learning needs,the students undertake self-directed research and critiqueof the learning needs. The teacher must ensure thatadequate resources are available for the students, eg:books, lectures, videos, patients, computer programs.

Feedback session This follow-up session summarisesand integrates learning. The group meets to discuss thematerial researched. The exchange of material and its

integration with the original problem may generate furtherlearning needs. These can be similarly researched. Theteacher should facilitate the exchange and the groupsunderstanding of the material. A number of sessions maybe necessary to cover all the material.

Evaluation This stage entails generalisation andconclusions. The group makes sense of, and drawsconclusions from, the material they have researched andpresented. Students can evaluate how successful theyhave been in fulfilling their identified learning needs.

BrainstormingIf creative solutions are being sought, brainstorming is aparticularly attractive technique. Free discussion by the smallgroup promotes initiative and lateral thinking. It can breakdown traditional linear patterns of thinking. A topic is selected,usually by the teacher, for which solutions or strategies areconsidered. Brainstorming may form the first stage of aproblem-based learning session, when the learning issuesare identified. Brainstorming has a simple three-stepsequence.

Generate ideas For example, students may be askedto describe the different ways medication/drugs can beintroduced into the body. The students then offer thesesolutions/strategies which the teacher writes on a flipchartor board.

Clarify ideas The ideas are clarified, and categorisedinto different areas.

Evaluate ideas and summarise The different ideas orcategories are then evaluated. The merits of each areconsidered.


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Race and Smith (1995) offer tips for brainstorming. Here arefive of their best.

1 Suggest that all ideas are welcome One of thefundamental principles of brainstorming is free thought.Especially in the early phases, no ideas should receivecriticism or rebuke.

2 Allow anyone to pass Participants should never bemade to feel inferior if they have no new ideas to offer.

3 Get participants to write their ideas on Post-it Thesecan be stuck to a flipchart (or a wall) in any order. Thatcan be altered as the general flow of ideas changes.

4 Continue till there are no more new idea Sometimes,you may feel that all the useful ideas have already beencontributed. It is important to wait until all your participantshave had their say. This gives them ownership over thewhole range of ideas that will be explored and developed.

5 Keep the products of brainstorming in view For example,stick up flipchart sheets on the walls. Show that you valuethe results of brainstorming sessions by referringappropriately to these sheets as the session progresses.Remember it is never too late to add further ideas toearlier flipchart sheets.

Role playStudents take on various roles and enact a scenario. Roleplaying is particularly valuable in exploring communicationissues and attitudes. The teacher negotiates or selects which

students plays which role and the teacher may also choosethe scenario.

Through role playing, students encounter situations that theymay go on to meet in practice. Participants act out roles inthe manner expected of those roles. Steinert, 1993 gives aparticularly useful description of role play in clinical teaching.Students may play their expected role in practice: they mayalso play the recipients of that practice. For example, in onescenario a student may play the role of a house officer askedto break bad news to a patient. In a second scenario, thesame student may play the patient receiving bad news, to

engender the feelings that patient experiences. Anunderstanding of how that patient feels may help the studentto relate to that patient. In the first scenario, the participantpractises an activity they will go on to perform. In the second,the student is trying to gauge how the patient feels. Becauserole play allows feelings to be explored, students can rehearseand improve their performance in affective areas of medicalcare.

Procedure for a role play Describe the nature of thesession. Assign roles. Ensure every individual has a clearunderstanding of their role. Give a task to one or more of

the role players. The tutor may feel that he or she shouldplay one of the roles. Ask the students to enact aninteraction. Videotape this, if possible. Later playback will

allow more meaningful and constructive feedback. Notall members of the group need play a role. Some maywatch the role-playing activity.

Debriefing Crucial for affective objectives. It is importantthat feedback is constructive. Generally, the person whoacted a task should be asked to describe what they think

went well. The facilitator, and observers of the role playshould highlight aspects they think were handled well.The role-play participants then describe what they woulddo differently, and the rest of the group also commentson what should be changed.

De-roling Before the role-playing students leave theeducational session, they must de-role. Their roles mayhave been emotionally highly charged. Allocate time forthe students to return to their real-life roles and to offloadany emotions. Some role players will easily de-role. Othersmay require a quiet reflective period, to dissipate the

feelings associated with their roles.

Games and simulationsBecause they allow a degree of experiential understanding,simulations and games are becoming increasingly popular.To ensure effective transfer of procedural skills, the bestapproach may be to train people on the job. The next bestapproach may be simulations or games that reflect the job(Tiagarajai, 1993). Participation may engender feelings thatbenefit, equip and empower participants (Crosby andEastaugh 1994).

For success in a small group setting, the teacher must befamiliar with the game or simulation procedures and itsobjectives. The teacher should introduce the game to thestudent players, if necessary explaining the rules andregulations. During the game, the teacher may also be aplayer or may facilitate the game. After the game, the teachershould conduct a debriefing session. This will clarify whathas been achieved.

Experiential methods, such as gaming and simulation, ensurethat teaching and learning are focused on the learner. They

permit fine words on small-group learning to be translatedinto practice (Percival, Lodge and Saunder, 1993).

Computer programs that simulate practice can successfullyraise issues, letting participants practise a variety of scenarios.For example, the MACPAC (1996) computer program allowsstudents to manage various patients with terminal cancer.Students can choose individually, or through groupdiscussion, their preferred management strategies: on whatinformation to ask for, what members of the team to involve,what drugs to prescribe. The MACPAC program is timedependent, allowing participants to see the consequencesof their decisions.


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Simulation and gaming are growth areas in small-grouplearning. Every year, a simulation and gaming yearbook ispublished by Kogan Page, which you may find inspirational.

Clinical teaching

Often the most familiar small-group method used by medicalteachers, clinical teaching remains the cornerstone of medicalteaching (McLeod and Harden, 1985). It is frequentlyconducted around patients bedsides. Clinical skills centresare growing in popularity: these reproduce the clinicalenvironment through the use of patients, simulated patientsand models.

McLeod and Harden (1985) consider the group-instructionalskills of the clinical teachers to be the most importantdeterminant of effective clinical teaching. The clinical teachermust also: ensure there are relevant patients for the session,

understand the stage of the students education, have a clearidea of the sessions objectives.

Educationalists tend to differentiate objectives into threedistinct areas: cognitive, psychomotor, affective (Bloom,1956). This division is artificial. The artificial division is madeonly to simplify the teaching - not to simplify the task. Whenperforming a task in practice, all three are frequently required.Clinical practice requires communication skills, perceptualskills, manual skills and management skills (Cox and Ewan,1988). For example, to take a blood pressure: psychomotorskills are necessary in the manipulation of the cuff; cognitive

skills are involved in the ability to recall the normal diastolicand systolic values; affective skills are needed forcommunication with the patient. Clinical teaching allows theintegration of all three types of objectives.

Several models can be adopted in clinical bedside teaching.Their details are beyond the scope of this article. However,as a rule of thumb, psychomotor demonstrations should havefive steps (Table 1).

Table 1 - Five steps in a psychomotor demonstration

Activity Example

1 Teacher demonstrates Take a blood pressure (using a student,patient or video)

2 Teacher demonstrates Explanation of what is happening (may

and describes actions not be necessary if a video is being used)3 Students attempt Take a blood pressure

4 Teacher/group Good points and points forconstructive feedback improvement

5 Practice Take blood pressure

In psychomotor demonstrations, student numbers involvedare crucial. Every student must be able to see thedemonstration. Various media may be used, eg, video,patients, simulated patients, models.

The nature of the observation is one problem in demonstratinga psychomotor skill that the student is asked to observe.Students have been known to observe and to copy irrelevantmannerisms from their tutors (Tiberius, 1990). It is importantto explain beforehand the essential aspects of ademonstration. Because psychomotor skills will not beacquired immediately, practice and repetition is important(Cox and Ewan, 1988).

More techniquesMany more techniques exist than are described here. Formore detail on group-learning techniques, try the books byJacques (1986) and by Tiberius (1990).

Checklists for effective small-group workThe following checklists have been generated for runningsmall-group work. The three checklists apply: prior to, duringand after the small-group activity. The lists will act as practical

guides for teachers adopting small-group work. Althoughpoints are numbered, some may occur simultaneously ratherthan sequentially.


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Prior to the small group activity

Consider the objectives of the session

Do I want to use small groups?

Small groups are one of many teaching method available.Consider carefully the objectives of the session or courseyou are running. Consider all the teaching methods available,eg, lectures, small-group learning, independent learning.

Determine your available physical andmanpower resources

What is available? Who is available?

Physical resources Practical constraints may prohibitgroup work. Accommodation and resource availability maybe limiting factors. Small groups require suitableaccommodation, which allows chairs to be set out in acircle. This circular layout maximises the interactionamong the students. There may also be a requirementfor: flipcharts, overhead projectors, patients, models andsuch learning materials as books or computer programs.Generate a list of how many rooms you require and what

equipment is needed to stock them.

Manpower Small-group teaching invariably requires theparticipation of a larger number of teaching staff. Considercarefully how many teachers are available to run small-group sessions. Those teachers must also possess theexpertise required of a small-group facilitator. Whatexpertise does a facilitator require to run a small groupeffectively? Can floating facilitators be used? Can a varietyof facilitators be used for one group? Can studentsfacilitate their own groups?

Does a facilitator have to be an expert?

One issue is the identification of appropriate teachers. Shouldthe teacher be an expert in small-group work? Should theteacher be an expert in the content material? Should theteacher be expert in both?

Research results are unequivocal. For small groups tofunction effectively, the facilitator must be familiar withfacilitating small-groups (Barrows and Tamblyn, 1980;Barrows, 1988). Eagle, Harasym and Mandin, (1992) alsofound that it is important for tutors to be well informed about

a problem and about related learning issues. Wilkerson, Haflerand Liu (1991) looked at the effect on small-group work oftutors with content expertise. They found that content experts

tended to have a more directive role. They concluded thatcontent experts may endanger one of the most importantaspects of small-group work - the development of studentsskills in active and self-directed learning. Silver and Wilkerson(1991) considered that content experts may have deleteriouseffects on collaborative learning. Content experts were foundto talk too often and too long. They also provided directanswers to students questions and suggested more topicsfor discussion. In problem-based learning, expert facilitatorswould spend more time on generating learning issues thanstudents would on resolving them. However, usinginteractional analysis, Davis et al (1990) showed that studentsevaluations and performance were higher in groups led bycontent experts than in groups led by others.

Ideally, the facilitator should have expertise in content and insmall-group facilitation. If this is not possible, closely examinethe small-group method adopted, the objectives of the sessionand the facilitators available. For example, a free-discussiongroups objective may be to explore the group membersopinions on euthanasia. The content is less important thanthe groups requirement to discuss the issue freely. A contentexpert may be unnecessary. However, in a tutorial, thefacilitator must be a content expert or one must be available.Although an expert facilitator can encourage group membersto explore issues of contention, a content expert should alsobe available. However, it is important that the tutorial doesnot become a mini lecture but that the content expert is thereto clarify or address points of content error.

In problem based learning, a content expert is usuallyunnecessary in the first three stages (first meeting,introduction of problem, self-directed study). The facilitatorneed only be familiar with the learning issues the studentsare expected to generate. However, a content expert shouldbe available for the final two stages (feedback and evaluation).This division of facilitation may allow the role, and the timedemands, to be shared.

Can a variety of facilitators be used for one group?

Ideally, continuity of the facilitator is desirable. The facilitator

can be considered as a member of the group. Changing thecomposition of the group may disrupt the group dynamics.Ideally, ensure that the same facilitator is used for the samegroup. If this is not possible consider the task of the groupand the importance of the role of the facilitator. Floatingfacilitators or student facilitators can be considered.

Floating facilitators

Some medical schools may find it difficult to recruit and sustainenough facilitators for every group. A floating facilitator canbe responsible for maintaining the task and function of more

than one group. That facilitator moves from group to group.


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Success varies, frequently depending on the dynamics ofthe groups. This technique is useful in seminars and in thesecond (problem introduction) stage of problem-basedlearning. Floating facilitators often work best after the grouphas already met three or four times. The technique may beused in conjunction with student facilitators.

Can a student facilitate his or her own group?

It may be appropriate to have a student act as facilitator orcarry out certain of the facilitators responsibilities. Studentswill have identified many of the behaviours exhibited by afacilitator. The role of a student facilitator in a peer groupdepends on the groups dynamics, on that students abilityand on the instructional details given to the students.

Members of a group may spontaneously and unconsciouslyfulfil some of the facilitators functions. In a more structuredapproach, each member of the group takes responsibility forone or more aspect. For example, one member of the groupensures that quiet members are involved in the activity;another takes responsibility for summarising information. Thestaff facilitator should suggest this division-of-labour approachto the group, allowing members to select the function theywish to fulfil.

Gauge which students will respond to this new responsibility.You may find that many students will facilitate naturally. Onestudent may express concern to hear other members of thegroup. Another may be conscious of the time available.Another may summarise information. The ability of studentsto act as regulators of their own group will develop with time.

Determine the group size and groupmembership

How many students can I effectivelyfacilitate?

You may have little or no input when students are allocated

into groups. If so, find out who is and obtain their rationale forgroup size and constitution. Allocation methods include: selfselection, strategically determined, randomised, alphabetical.

If you wish groups to contain a diversity and breadth ofexperience, do not allow students to self-select their groups.People will naturally select those who are most likethemselves This results in focused, but unchallenged, groups.

Strategic selection, though time consuming and sometimesdifficult to arrange, maximises the benefits from small-groupwork. Consider factors such as: gender, nationality,

experience, age. People can learn most from those least likethemselves. Strategically determining groups is the bestmethod to adopt but frequently is more time consuming anddifficult to arrange.

Randomisation or an alphabetical system by surname arefrequently used. Their only merit is simplicity. Avoid thiscomplacent approach.

Groups can become stale. It may be appropriate to change agroup after a designated period of time. This may besemesterly or yearly. Ask the students for their thoughts onthe matter.

Some teachers do not keep constant groups. They randomlychange the groups, offering the students diversity and thestimulation of working with new partners. Such teachers areusually confident, and would themselves crave the variationoffered by changes. Students may also argue for changes,especially if they have had little contact with other membersof their year and are in the early stage of group development.Reshuffle groups, if you have clear reasons for this action.An objective of using small-groups may be to improve groupinteraction. Regularly changing the group may be a thoughtfulstrategy. Remember - groups will work less productively ifconstantly changed, as they are less likely to reach aproductive stage.

Ensure that the staff are prepared for thesession

Will the staff know what to do?

Small-group methods require an understanding of facilitation.For the successful introduction of small-group work, staffdevelopment is a key feature. This is especially true if previousapproaches were traditional. Staff must be given prioropportunities to see small-group work in action and to attendstaff development sessions.

Select the most appropriate small-groupmethod to fulfil the objectives

Which method would be most effective?

Small groups are not always the most appropriate method ofteaching. Study the objectives of your course. Thoseeducational objectives should determine the delivery of allsessions and the nature of assessment. Consider smallgroups, lectures and independent learning - then decide whichmethod is most likely to achieve each educational objective.

If there are no practical constraints, appraise each objective

carefully. Small-group methods may fulfil a range ofobjectives. For simplicity, the GMC separates objectives intothree areas: knowledge, skills and attitudes (GMC, 1993).The terms cognitive, psychomotor and affective are frequently


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used as equivalents (Bloom, 1956). As mentioned earlier, indelivering health care, such objectives cannot be easilyseparated. In consequence, they should not be taught orlearnt separately. However, it is useful to identify the objectivesthat you wish to be learnt.

Cognitive objectives Such as knowledge,

comprehension, application, problem-solving, analysis,evaluation. Examples of cognitive objectives include: listthe five major groups of therapeutic drugs in the treatmentof ischaemic heart disease; compare and contrast thehistology of normal arteries and arteries withatherosclerosis. Small-group methods that may fulfil suchobjectives include: problem-based learning; tutorial;seminar.

Psychomotor objectives Often, these can only betaught in small groups and ideally one to one.Psychomotor objectives include: record a blood-pressure

measurement; insert an intravenous line; take a bloodsample. Clinical bedside teaching is a clear example ofsuch learning.

Affective objectives This includes the exploration ofnew relationships, the connection of emotional andintellectual concepts, the production of imaginativesolutions to problems. Attitudes and communication maybe aspects of affective objectives. Participation as amember of a small group may lower interpersonal barriers.Examples of objectives include: impart bad news to apatient or relative with empathy and sympathy; inform acolleague that you consider a present line of managementto be inappropriate; describe a line of management to apatient. Such objectives may be fulfilled by role playingor free-discussion groups.

Develop stimulus material

What type of material will generatediscussion, problem solving and creativity?

The teacher has a responsibility to prepare for any sessionor course. Small-group teaching is no excuse for the facilitatorto reduce preparation time. The preparation of stimulusmaterial may include: the writing of problem-based scenarios,the production of video clips, the formulation of questions,the identification of key articles for exploration, theidentification of appropriate patients. Prior reading, perhapsfocused on issues, is also important. Although you are the

teacher, you may not always have the answers. You should,however, know how the answers can be sought. If necessary,you should direct students to sources. Preparation may entailensuring that learning opportunities, such as books orvideotapes, are available to the student.

Your stimulus material will be determined by the small-groupmethod you adopt. It may take three forms:

Material prepared before the session but which doesnot act as a focus for the session For example, thismay be a series of lectures or an article. The students willnot bring the work to the session. They will use the materialto identify deficits in their understanding. During thesession, they can discuss these deficits and seek greaterunderstanding.

Material prepared for the session and acting as a focusfor the session This may be made available in a varietyof ways, eg, a study guide (Laidlaw and Harden, 1990) ora handout. The students prepare questions on the materialand bring the material to the session. Their questions maybe directly focused on the material.

Material unseen prior to the session New stimulusinformation may be introduced to the students at thebeginning of a session and during the session, eg aproblem in problem-based learning. If new information isbrought to a session, the teacher must ensure that thestudents understand it.

Small-group sessions around computer packages provide an

example of introducing material during a session. As studentswork through a program, new material will be accessed, whenappropriate. The level of the students understanding willdetermine what new material is revealed. In this way, thecomputer is not only introducing new material but is helpingthe students to learn.

Inform students about course objectives andhow small-group work fits in

Do the students understand the rationalefor using small groups?

Students have to understand why small groups are beingadopted in the curriculum. Their role and how they relate toother activities should be clarified. If students see small-groupwork as peripheral, their commitment may be minimal.


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During the Small Group Activity

Allow adequate introductions use ice-breakers if necessary

Is this group new or a previously formedgroup?

Irrespective of the small-group method utilised, consider usingan ice-breaker if a group is meeting for the first time. Thistechnique is especially valuable for groups meeting onlybriefly.

An ice-breaker, which should not be used twice with the samegroup, is a brief activity that relaxes and introduces themembers of the group. The normal tension and coolness

between strangers is reduced. By accelerating familiarity, anice-breaker allows greater communication and discussionwithin the group.

For the simplest ice-breaker, each member of the groupintroduces themself, describes their background and lists theirexpectations of the course. The teacher can also ask groupmembers to write down, anonymously, any fear or concernthey have about small-group work. Once these papers arecollected, the teacher can share some of the concerns withthe group and attempt to alleviate them. Even in large groups,there are seldom more than three or four major concerns. It

may put group members at ease to know that other peopleshare their apprehensions.

An ice-breaker is the ideal way of introducing group membersto each other. You might feel that this is inappropriate orunnecessary. However, it is important that all members ofthe group know at least the names of the other groupparticipants. If necessary, ensure that formal introductionsare made.

Establish ground rules Some people may feelthreatened in a small group. To maximise the security of

the educational climate, particularly when exploringaffective objectives, suggest that members generate alist of rules. These may include:

confidentiality is maintained, especially if patientsdetails are to be discussed

contributions are always received positively

members are not ridiculed or humiliated

only one member talks at any one time

all members must contribute

Ensure that the students understandwhat to do

Do the students know what they are doing?

Do they know why?Do they know how they should achieve it?

The students must know the task or purpose of the small-group session. Give them clear explanations. If you are unsurethat the group understands the task, ask for clarification.Identify a time frame. The task will depend on the nature ofthe objectives and on the small-group method adopted. Thework may be carried out in a laboratory, at the bedside, bycollecting material, or in a classroom discussion.

If you are satisfied that group members understand the natureof the activity or task, ensure that they all understand thesmall-group method. Students should appreciate the stepsinvolved in various methods. A clear pathway should beapparent to the student.

Facilitate learning

How should the group be maintained toachieve the task?

The teacher, facilitator or tutor should facilitate the studentslearning. The term teacher fits uncomfortably into small-group work, carrying a hierarchical overtone. The facilitatorsobjective is to help the student become more self-reliant andindependent. As a resource for learning, facilitators are betterthan a didactic teacher with all the answers (Brookfield, 1986).Barrows (1988) suggests that the facilitators use ofappropriate skills is the major determinant of the success ofsmall-group methods.

A facilitator should establish a climate that is open, trustful

and supportive (Eagle, Hayasym and Mandin, 1992). Barrowsand Tamblyn (1980) consider that a good facilitator will askstudents to elaborate points, will clarify why questions areasked, will probe the students understanding of principlesand concepts, will summarise and will challenge hypotheses.Wilkerson, Hafler and Liu, (1991) also consider goodfacilitators to be those who enhance student-directed learning,and encourage students to listen, to tolerate silence and tointerrupt one another infrequently. Brill (1978) describesfacilitators as being in a helping relationship.

In a professional setting, we all tend to work in small groups.

However, there is seldom a facilitator to ensure the smoothrunning of the group. An educational facilitators role has twodistinct areas: maintain the functioning of the group; ensurethe task is completed.


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Maintenance of group functioning may include: encouragequiet members to contribute; ensure some members do notdominate the discussions; promote cohesion within the group;reduce tension or conflict (Jacques, 1986). Group memberscan be encouraged to speak by using open-ended questions.Do not ask a student: Differentiate the pain of acutemyocardial infarct from the pain of an angina attack.Rephrase it to: Can you tell me something about the type ofpain experienced during an acute myocardial infarct and thepain of an angina attack?

To maintain the function of the group, the facilitator mustobserve what is happening. Reynolds (1994) suggests thefollowing framework for observing students in a group.

Communication Who is or is not actively involved?Who talks to whom?

Decision making Who makes decisions? How are theymade?

Power and influence What is the pattern of power?Does the power change over time?

Conflict Are conflicts in the group resolved? How arethey resolved?

Ethos What roles and rules have developed? Whatvalues has the group demonstrated?

The facilitators part in ensuring that the task is achieved mayinclude: open the discussion, summarise points, clarifyingpoints, synthesise ideas, give information and opinions,question unclear contributions (Jacques, 1986).

In the early stages, group maintenance and task completionare the responsibilities of the facilitator. However, it maybecome appropriate to hand over these roles to members ofthe group. In an educational setting, a good facilitator is onewho makes herself or himself redundant.

By responding to issues and situations that arise within agroup, a facilitator should ensure the effective functioning ofthat group. All possible events cannot be predicted. Thefacilitator must observe what is happening, interpret thoseobservations, analyse the problem and devise strategies toimprove the functioning of the group. Such strategies improveas the facilitator becomes more experienced. Mistakes willbe made. Reflect on good practice and bad practice. Deviseyour own guidelines for effective small-group facilitation.Remember your actions should never jeopardise theessential characteristics of small-group work. Remember toothat small groups are dynamic and will alter over time.

Group dynamics Facilitators must understand thechanging dynamics of a group. Frequently, as a groupmatures, its potential, and effectiveness, increase

markedly. Some writers use a family model to describethis change in a group. Resist the temptation to use afamily analogy. A family has a clear hierarchical structure

unl ike an effectively functioning academic group.Tuckman (1965) suggests a group may experience fourstages:

Forming an exploratory stage, where members of agroup attempt to discover more about other members.This may be an awkward stage, characterised by

silence. Storming members of the group confront each other.

Attempts are made to control the group. Open conflictmay become evident. The accountability andresponsibility of group members is an importantdeterminant of their effectiveness in the group - andmay also be the focus for some storming (Guidi, 1995;Parsons and Drew, 1996). Students may object thatgroup work places the onus on the mature, organisedstudent to contribute to the session. Accountabilityshould be taken by all members.

Norming rules, in an attempt to minimise any furtherconflict, are formulated for the behaviour of groupmembers. The rules are generated by each group andmay not be applicable to other groups. During thisnorming stage, group members conform to theformulated rules.

Performing the group focuses on the task, eg, thestudents focus on achieving the learning outcomes.This is a productive period.

A fifth stage, suggested by Tuckman and Jensen(1977), is associated with group dissolution and theassociated emotions. For ex-members, the group hadbecome an integral part of the learning process.Students may express appreciation, describing howthe group experience has influenced them (Walton,1983).

For any one group, the duration of each stage may vary. Forexample, a group may pass through the storming stagewithout any outward signs. It may stay at the norming stagefor several hours or for several days.

Facilitators must be aware of these stages. That knowledge

will help put into perspective any discouragement ordisillusionment experienced during a stage (Walton, 1983).The storming phase can be extremely painful and disruptive.However, the phase will pass. As a facilitator, you may beable to give some insight into what is happening. During thestorming phase, members may ask to be assigned to anothergroup. Resist the temptation to change members of anestablished group. We seldom have that luxury in real life.Also, a group with a new member would have to go throughthe stages again. Further, the problems observed in one groupmay simply be replicated in a new group. Conflict should beidentified and resolved.


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Debrief the group on the activity

What has been achieved?

Maximise learning with a debriefing session. Debriefingsummarises or clarifies what has been learnt and may takeas long as the activity itself. Do not neglect this session. Itmay tie up any loose ends and make sense of the experience.It may also set the scene for further small group sessions.

During debriefing, constructive feedback may be given. Thisis especially important for student presentations, role playsor psychomotor skills. Schofield (1983) gives guidance onconstructive feedback:

briefly clarify matters of fact

the individual in question goes first, then other students,

followed by the facilitator

focus on the good points first students will readily identifyareas of poor practice

constructive points identify points for improvement

discuss disagreements

the learner is left with a clear summary of strengths andweakness.

If affective objectives have been explored, it is important tostart by describing what happened in terms of events ratherthan how it felt. A member of the group may relate whathappened in a game or may reflect on how the group worked.This is non-threatening. It allows members of a group to startanalysing their small-group experience.

Members of the group should be asked for the outcome ofthe groups activity. For cognitive objectives, this may be alist of solutions for a problem. For affective objectives, it may

be a description of how they felt. For psychomotor objectives,it may be the successful completion of the procedure.

After the Small Group Activity

Evaluate the success of the session

What happened?

As with any teaching method, it is important to evaluate thesuccess of the session. There are two aspects - achievementand quality. Have the objectives been achieved? This aspectmay be evaluated by how successful the studentsassessment is. However, students are resilient. They maylearn the material, even if the session is of low quality.

Was the educational experience of a high standard? You couldask students to complete an evaluation questionnaire. Includethese four questions:

Did you understand the objectives of the session?

Did you find the group setting a supportive environment?

Were you motivated to learn?

Did you feel that the session met the objectives?

Such questions limit the evaluation. Complement them withopen-ended questions and involve free-text responses,

What did you like about the session?

What did you dislike?

What would you change?

Alternatively, the session could be peer reviewed. In everycase, you should consciously self-evaluate the session. Asfacilitator, you are in a prime position to evaluate groupperformance and development. You may use a formal or

informal checklist. Acknowledge good and bad aspects of asession. Reflect on events. This will promote better practicein future. However, beware of too much evaluation. Constantevaluation may inhibit the development of the small group(Newble and Cannon, 1989).

Reflect on the experience

How can it be improved next time?

Evaluation, formal or informal, is pointless if no change inpractice results. Competent evaluation, no matter howfavourable, will always identify areas for improvement. Taketime to consider what changes need be made. Also, considerthe introduction of new methods or ideas. If the changes aremajor, perhaps you should try out your new ideas with a smallpilot study. Reflection cannot be effective in isolation. It shouldbe ongoing, and an integral part of your teaching practice.


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ConclusionsSmall-group methods have a valuable role to play inundergraduate medical curricula. The student-centred focusand active participation enhance the likelihood of deep ratherthan surface learning. A key question currently challenging

medical curricula is: How much time should be scheduledfor small-group work? Some schools have little or no small-group work. Others adopt small-group learning as theeducation strategy for delivery of a curriculum. Others havea mixed approach, with small-group work one key componentof the overall course.

If a medical school decides that small-group work has certainmerits, it must decide what kind of small-group work to adopt.Seminars, tutorials, role-playing and problem-based learningare a few examples, described in this article. Each methodhas its strengths and weakness. The methods must be

selected to match the objectives and also the expertise ofstaff. Staff may be unfamiliar with certain methods. Consideraddressing such deficits. It is likely that all teachers, at sometime, will take part in some form of small-group teaching. Thisimportant method of learning should feature in staffdevelopment.

If small groups are used, they must be valued. If seen asperipheral, small-group work will not be easily accepted bystaff or students. Whatever percentage of the curriculum issmall-group based, whatever small-group method is adopted,

group learning must not be seen as isolated from otheraspects of the curriculum or from the culture of the medicalschool. If run badly, small groups may be unpopular with staffand students. The methods may then fall into disrepute. Toavoid this, staff and students must fully appreciate the processof small-group work including its aims and intendedoutcomes. Success depends on good planning and effectivefacilitation.

Success also depends on a movement away from teacher-centred learning. In a traditional approach, teachers had thesatisfaction of knowing that they had covered a subject. That

students might not have learnt the material is ignored. Therewas an inbuilt urge for teachers to teach, rather than to allowstudents to learn. For a real and sustained shift in medicaleducation, teachers must grasp the fundamental truth students must be encouraged to learn rather than merelycatching the output of teachers.

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