SAFILT Core Skills: Group Work and Group Dynamics

Facilitating debriefing of clinical simulation is all about working with groups. Sometimes members of the group will know each other, often they will not. Creating interaction between the group members can be challenging, with members concerned about their abilities and limitations being on show to others. Facilitating newly formed groups sensitively requires knowledge applied to practice, and effective group work can be a defining factor of learner satisfaction of the simulated education process.

Although most facilitators already have a set of skills that enable them to feed back and debrief small groups, there are different ways in which groups function. This means that facilitators may have to adapt their debriefing style and be aware of group dynamics in order to ensure a satisfying experience for those participating in clinical simulation. Groupwork skills can also be used away from debriefing as an effective tool for learning in the clinical setting.

Introduction

For junior doctors progressing to Foundation Years 1 and 2 this is a critical period. Although well qualified theoretically, their clinical skills are limited, as are the non-technical skills of cooperation with other members of the health care team. In clinical simulation, their skills and limitations are open to observation by their peers and experienced clinicians, and this can be anxiety provoking when they come together as a group for simulation debriefing.

Knowledge of how groups work and what can make them ineffective is vital in supporting productive learning.

A Well-Known Theoretical Model

Bruce Tuckman developed one of the most famous models used for understanding groups: 

Forming, Storming, Norming, and Performing – developmental sequence in groups. Essentially this refers to orientation, interpersonal issues and resistance, cohesion, and the channelling of group energy to achieve a task. These stages can be discerned even in groups formed for very limited periods. Tuckman later added a fifth stage – Adjournment – but this is covered more in the section on critical feedback.

Forming
    
Often characterised by:

• Shyness
• Uncertainty
• Reservedness
  

Concerns at this stage are group maintenance

Storming

Characterised by vying for position, authority, and influence. This can be a very testing time for the facilitator, who may have to deal with arguments and disagreements until the group settles into agreed behaviours such as formal or naturally occurring ground rules.

Norming

The group begins to form an identity and implicitly sets ground rules of appropriate and acceptable behaviour. In so doing the group may periodically slip back into a storming phase.

Performing

The group is now at the stage of getting work done within a stable structure.  
Practical Application

Clinical simulation days for Foundation Programme doctors mean that they may be thrust together in various ways: From different Trusts, different educational establishments, and could be a mixture of years 1 and 2. Therefore their familiarity with each other and methods of learning and working may be different.

Given the short amount of time that they are with the simulation centres, these phases need to be worked through and addressed quickly. The facilitator can support this by constructing a framework in which this process takes place:

Forming

The first and introductory session to the day should provide an atmosphere that is comfortable to practice and speak in. It should provide an outline of the day’s activities and their purpose. Consulting with the group regarding the setting of ground rules for behavior for the day is also a good strategy – if anybody oversteps the mark they can be referred back to the jointly agreed principles.

It may be useful to provide an activity at this point which enables this, such as a workshop or analysis of a piece of video which they work together on. This could be a specific element of a scenario, such as communication or teamwork for instance.

Storming

There may be conflict arising between members. They are under pressure and observation in clinical scenarios and anxious to do well. If others are perceived to fall short this may lead to disagreement. The facilitator needs to manage this if necessary, and to remain constructive in ensuring all parties are heard and listened to (hearing is not the same as listening) so that they can begin to work more cohesively. There may also be some jockeying for positions of authority that need to managed, which the group may need the help of the facilitator to achieve.

Norming

The group begins to recognize itself as a collective, with its own sense of identity. Whilst confronted with scenarios that are usually individually or encountered in pairs, the group begins to see itself as a team. This does not mean that all will be harmonious, as members may revert back to the storming phase periodically. Facilitation is required to support the members in enabling them to realize that they will gain more from the day if they work collectively on the issues that arise. A further point is in how the participants get from superficial congratulatory feedback from scenarios to honest and constructive feedback. This requires careful maintenance and development by the facilitator.

Performing

The group is now at a stage where it is ready to work well and more collaboratively. The facilitator needs to be mindful of the group processes and dynamics before this point is reached. The aim should be to develop greater coherence and interaction of the group as the day progresses. Optimum group performance is unlikely early in the day because it needs to orientate and establish patterns of working together. This includes feeling personally secure, so a climate of trust is a useful strategy to develop.

Finally, an ‘adjourning’ component needs to be built into the end of the day. It is important that the group is not just left to say goodbye. The ‘what happens now’ consideration of where individuals intend to take their performance is vital to ensuring a considerate end to the experience.
    
Group Interaction

As a facilitator you need to make some decisions as to the format of the debrief based on your educational goals for the day (see designing optimum learning environments). How you set yourself up as a facilitator will be modelled by the group. If you choose to be directive, the group will interact mostly with you. If you choose to be more ‘facilitative’ the group will begin to interact more with each other.
The kinds of questions you ask will lead this process. Appreciative questions are more likely to develop interactions than directive or closed questions. If facilitation is overly directed it is easy to miss those who sit quietly but who might have something valuable to say.

ACCESS THE VIDEO FILE GROUP_WORK_&_DYNAMICS_1 NOW USING THE BUTTON AT THE TOP RIGHT OF THIS WEBPAGE

In this clip is an example of the experience of coming together as a part of a new group and exposing your limits to others.  By reinforcing the ‘group identity’ over individual perceptions of limitation this can be minimalised.

Patterns of Communication in Group Work 

It is useful to evaluate the directions in which debrief conversations take place. A simple way of doing this is by providing an illustration of these patterns. A few moments time-sampling these throughout the day will give you an indication of communication patterns. It may be useful to ask a colleague to observe you and do this as part of your developing practice. Below are some examples of this:

A) Pattern for 1.30 - 2.30

B) Pattern for 2.30-30.30

So what might be the catalyst to changes in this participation pattern?

There is no right way of facilitating participation. The levels and patterns of interaction may vary, but to make the experience more engaging and satisfactory it is usually better if there is as broad a participation as possible across the whole group. Questions that may be put to a group to help it understand its patterns might be:

• How much of the talking is done by the leader, how much by the other members?
• To whom are the questions or comments usually addressed – the group as a whole, the leader or particular members?
• Do the members who don’t talk much seem to be interested and sitting alertly (non-verbal participation), or are they bored and apathetic? (Jaques, 1998)

A visual map of the directions of interactions occurring at different times of the session such as that above can assist in identifying your style of facilitation and how it can be adapted. Charting these may provide the basis for an analysis of why these might be different and ask questions of the strategies used for facilitation.

Gilkinson (2003) provides a useful table that supports the principles of facilitating problem-based-learning. See the section on giving critical feedback. This also gives some useful pointers towards effective facilitation

ACCESS THE VIDEO FILE GROUP_WORK_&_DYNAMICS_2 NOW USING THE BUTTON AT THE TOP RIGHT OF THIS WEBPAGE

A further way of developing group work is by using groups to take specific roles.  In these two clips we see how this can occur of particular behaviours, the group has a specific identity within which members are able to be collectively critically constructive with their colleagues.

ACCESS THE VIDEO FILE GROUP_WORK_&_DYNAMICS_3 NOW USING THE BUTTON AT THE TOP RIGHT OF THIS WEBPAGE

This is followed up by seeking some feedback from the second task-allocated group.

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References

Heron J. (1993) Group Facilitation Kogan Page, London

Jaques D. (1998) Learning in Groups Kogan Page, London

Quilligan S. (2007) Communication skills teaching: the challenge of giving effective feedback. The Clinical Teacher 2007 (4) pp.100-105