2. Setting the Stage
a. Introductions
Introductions are important to small group functioning, and large groups can feel more included if you use introduction techniques. In small groups, every member should introduce him/herself by name. You should record each person’s name and where they are sitting so that you can use names when asking directed questions. This is particularly helpful when the group or an individual learner is not very interactive. You can request other information in the introduction as well if it will enhance small group dynamics or to provide you with additional insight into the learning needs and experiences of the learners. You may choose to ask learners to reveal their greatest challenge with patients who abuse alcohol, or their greatest success. Or, to understand your learners past experience better, you might ask them to tell of any alcohol or cross-cultural training they might have had in the past. With larger groups introductions are more difficult. If you need to understand the level of training in a large group of learners, you may use polling techniques: “How many of you screen all of your patients regularly for alcohol problems?” or: “Who had training in using the CAGE questions in Medical School?”
b. Create effective learning climate
Learning climate is the tone or atmosphere of the teaching setting including whether it is stimulating and whether learners can comfortably identify and address their limitations. Learning climate can be affected by the instructor and by participants. Issues like creating a safe place to try new skills, setting a coaching rather than an evaluative tone, and encouraging participants to take intellectual risks can be modeled by the instructor and reinforced through positive feedback. Particularly in small group settings, the make-up of the group may also affect learning climate. Every group has its own dynamic depending upon the size and composition of the group. Small groups are heavily influenced by the personality characteristics of their members. In the best groups, members balance each other, assist each other, and participate appropriately and proportionally in the learning activity. If a group is unbalanced, competitive or dominated by certain individuals, the learning process can be negatively influenced, and the instructor must intervene to restore a positive climate.
c. Set ground rules
Ground rules are especially important to small group teaching. Ground rules can be used to enhance learning climate or to intervene if group dynamics interfere with group functioning. Ground rules include things like honesty, confidentiality, focusing on positive feedback before negative, equal opportunity to participate, or allowing the option to pass on participation. Ground rules should grow out of your goals for the session as well as the nature of the group.
d. Review plans, goals, objectives
Or – “Tell them what you are going to tell them.” It is important from the outset that learners be informed of what to expect in the teaching session. This gets everyone on the same page and makes it easier to manage the agenda for the time allowed. Learners should be aware of what they need to do to be successful in the session and how they will be evaluated. They should also understand the purpose of your teaching – why are they learning this material? How is it important to their training?
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3. Teaching Methods
a. Provide instruction and opportunities for discussion, problem-solving and practice
Here is where you implement your methods to accomplish your goals. Again, always be careful not to attempt to teach too much in a too short period of time.
When planning your methods consider what learners need to know in order to practice and apply a skill, how they might get the opportunity to practice in your teaching session, and how they might translate their learning into clinical behaviors. In the ACT curriculum, materials are provided to you so that background knowledge can be reviewed (PowerPoint presentations) and skills demonstrated (video case discussions).
b. Using PowerPoint presentations
When using PowerPoint presentations with small groups (rather than larger groups), it is best to avoid excessive formality and to retain the more intimate nature of the small group. If possible, arrange seating in a U-shape, and remain seated during your presentation. This will encourage learner attention and participation throughout your presentation. PowerPoint presentations are an excellent way to convey content in an efficient manner. Visuals reinforce your verbal messages, and models or graphs can be especially useful. When appropriate, you can make your presentation more interactive by asking learners to explain concepts or models included in your slide set.
c. Using video cases
ACT video cases provide opportunity for observation of clinical examples, reflection and discussion. Depending on the group, video cases may trigger immediate relevant discussion, or may trigger irrelevant discussion or silence. Before using video cases, be sure to review them and prepare a series of questions should your group be the quiet type. Be sure to steer the group back on track should the discussion wander off topic (e.g., did you notice the beard on that guy??). If discussion is on-topic, be aware of the key points that you want to reinforce and use Socratic method to draw these points from the learners. You can do this informally or collect the points on a board or flip chart as discussion progresses.
d. Using role play (or skills practice sessions)
To allow an opportunity for practice you may use role play techniques using 2 learners or a learner and a standardized patient. Role play is a common method used to teach clinical communication and counseling skills. It is important to first establish a safe setting, by establishing certain ground rules like:
- Anyone playing the clinician in the role play is the first to critique his/her performance.
- Start with positive feedback, “What went well?”
- Model positive feedback yourself
- Provide corrective feedback like a coach, “next time try….” Or “you could improve your performance by…”
When using role play, assign both clinician and patient roles. Be careful with the patient role though. If you are teaching residents or practicing physicians and they devise the patient role themselves, they may portray the most difficult patient. Be sure to provide guidance to the “patient” about where they are willing to listen, respond, and compromise. For more on conducting role plays, see page ??.
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4. Activity
a. Manage the session
The greatest benefits of small group approaches to teaching are its potential for active learning, discussion, and the development of meaningful interpersonal relationships. The small group becomes not only the venue for teaching, but also a resource for teaching. Effective facilitation skills allow the instructor to manage and direct the resources of the small group to maximize teaching potential.
Managing the session is the manner in which teaching interaction is focused and paced as influenced by the instructor’s leadership style. A directive style is instructor-centered, with the instructor calling the shots, informing and directing the learners. This style requires the greatest effort by the instructor, and may be most effective in larger group settings. The democratic style engages students in making decisions by rule of the majority. This requires frequent polling and runs the risk of neglecting minority views. The non-directive style relies on the skills and self-efficacy of learners to take responsibility for leadership of group activities. This approach may be most effective in working groups. For most teaching activities, the instructor will adapt leadership style to be consistent with the learning activity. For example, a directive style would be appropriate for didactic presentations, a democratic style for situations where there are different options for learning, and a non-directive style for certain discussions.
b. Engage all learners
Engaging learners is an art form. The basis for engagement includes learner expectations, and interest in the content, but it is also highly influenced by the relationship between instructor and learner. Artful ways to encourage engagement include the use of facilitation skills.
Facilitation skills for teaching are similar to those used in physician-patient interactions. As in the clinical setting, eye contact, non verbals, knowing your learner’s name, open-ended questioning, and vocal cues like “uh-huh” and “tell me more” can help learners contribute to small group discussion. And, always be aware of the quiet learner – the one who may need an overt invitation to participate. Students who are shy about participation without an invitation appreciate instructors who 1) notice that they have not contributed; and 2) specifically invite their contribution.
Nonverbals and silence can be effective management tools not only to curb discussion when needed, but also to foster it:
- To foster discussion, pose an open-ended question and remain silent
- To encourage discussion from a quiet group member, look at him/her, or provide a verbal invitation to speak
- To close discussion look away, check the clock or interrupt if necessary. To stop a rambling learner use touch if possible
Focusing and expanding discussion can be accomplished using standard Socratic methods. To open discussion, pose a clinical case or open question. To expand discussion, add more open questions or different cases. Use “what if” scenarios to change the case or steer it in a more interesting or controversial direction. To focus discussion, use gradually more specific and focused questions.
Finally, be sure to avoid the common pitfalls:
__ When you ask a question don’t answer it yourself or try to reformulate it, count to 10 silently before speaking again
__ When you have something you could say (which is most of the time), count to 10 again
__ Look around the group both when you are speaking and when a learner is speaking. That way learner will quickly recognize that they are addressing the group rather than just you. It will allow you to pick up cues from those who want to speak but are inhibited
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5. Debriefing
a. Ensure learners have understood what has been discussed
Near the end of a teaching session, be sure to set aside time to summarize the main teaching points and to connect teaching to clinical practice. You may set goals for the learners, such as, “Try this with one patient tomorrow, and let me know how it turns out.” If there is additional reading or assignments that learners must complete, this is the time to review these items. It is also important to emphasize how the learner will be held accountable for learning. You can also ask learners to state what was the most important lesson they learned from the session.
b. Clarify confusing points
Take the time to ensure that all learners are clear about the content, how the content will be applied to clinical practice, and what learners are expected to do next. To elicit potential confusion, verbally quiz the students at the end of the session to ensure that they are clear.
c. Address clinical application
You can ask learners to state in which settings they could envision themselves using the material learned from the session. You can ask the whole to discuss potential barriers and facilitators to using the new knowledge or skills in their clinical practice.
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6. Provide and receive feedback
It is good to get into the habit of requesting feedback at the end of every teaching session. This will provide you with important information about the effectiveness of your teaching, and will also model your ability to hear and accept both positive and negative feedback on performance.
Providing feedback to learners about their performance should be an on-going process throughout the teaching session as well as during clinical supervision. Effective feedback is intended to reinforce the positive aspects of performance, and provide information and coaching on performance in need of improvement. In order to provide effective feedback, performance must be directly observed, and both successes and challenges noted.
Whenever providing feedback to a learner, start with learner self-evaluation. When you give a learner the opportunity to self-evaluate, he or she will often identify many salient problem areas, and will sometimes be even more critical than expected. Allowing learners to self-evaluate serves several purposes:
1. Reduces shame as learners can save face by recognizing performance problems first.
2. Provides you with insight into which problems learners are aware of, and which problems elude the learner’s awareness.
3. Provides you with an opportunity to correct misperceptions.
4. Develops learner’s self assessment skills and contributes to lifelong learning.
5. Makes your job easier as the most obvious shortcomings in performance are already on the table.
Some principles of effective feedback include:
1. Feedback should be expected. Be sure to set expectations for learners so there are no surprises.
2. Provide feedback immediately after performance if possible. If not, the sooner the better.
3. Be concise, focused, and objective.
4. Make your feedback specific to the performance you have observed. Include specific suggestions for improvement.
5. Highlight the positives to improve the likelihood that these behaviors will be repeated.
6. For problem areas, provide helpful advice, resources and suggestions to improve performance.
7. Remain future-oriented: “The next time you do this try X. You will find that it is a more effective approach.”
To enhance the learners receptivity for feedback, use the “sandwich” technique, starting with praise for something done well, followed by suggestions for improvement, and ending with positive reinforcement.
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