Effective Small Group Learning: AMEE Guide No. 48
2010; 32: 715–726AMEE GUIDEEffective small group learning:AMEE Guide No. 48SARAH EDMUNDS1 & GEORGE BROWN21University of Westminster, UK, 2University of Nottingham, UKMed Teach Downloaded from informahealthcare.com by Cleveland Clinic multi-site (Florida) on 05/13/14For personal use only.AbstractThe objective of this educational guide is to outline the major facets of effective small group learning, particularly applied tomedicine. These are discussion skills, methods, the roles and responsibilities of tutors and students, the dynamics of groups andthe effects of individuals. It is argued that the bases of effective small group learning are discussion skills such as listening,questioning and responding. These skills are the platform for the methods of facilitating discussion and thinking. The facilitatingmethods strengthen the generic methods, such as tutorials, seminars and electronic tutorials. However, the success of thesemethods is dependent in part upon the roles and responsibilities taken by students and tutors and the consequent group dynamic.The group dynamic can be adversely affected by individuals. Evaluation of the processes of small group learning can providediagnoses of the behaviour of difficult individuals. More importantly, studies of the processes can help to develop more effectivesmall group learning.IntroductionEffective small group learning in medicine is a much morechallenging task than is often realised; it is relatively easier tohave a meandering discussion with a group of medicalstudents. It is much more difficult to get them to discussconstructively, to question and, most important of all, to think.Indeed many texts and articles on learning in small groups puttoo much emphasis on the role of the tutor and too little on therole of the students. But, as Stenhouse (1971) observed,‘ . . . developing small group teaching depends as much onstudent training as on teacher training’. To this point, wewould add that an important part of the role of a tutor is to helpstudents to develop their discussion skills and thinking beyondthose attained in senior secondary school.This theme of using discussion to facilitate thinking is thecore of this Guide. It is therefore not directly concerned withsmall group learning in laboratories, skill centres, bedsideteaching or the operating theatre, although it is hoped thatthese sessions will involve students in thinking. Its purpose isto help less experienced lecturers and registrars to develop thediscussion and cognitive skills of their students, includinginterns, and their own skills in methods of learning which areprimarily concerned with interpersonal interaction e.g. tutorials and seminars. The Guide is also intended to refresh theknowledge and expertise of more experienced lecturers andconsultants engaged in teaching. It provides guidelines andsuggestions on facilitating talking and thinking in groups; itconsiders the various methods of small group work and itoutlines ways of evaluating the effectiveness of small grouplearning. Despite the importance of learning in small groups inmedicine, there has been surprisingly little research on smallgroup work other than in problem based learning (PBL).Practice points. Communication and cognitive skills of the tutor and thestudents are the basis of effective small group learning,not the methods used. Questioning, listening and responding are key skills fortutors and students to develop. Facilitating methods, such as thinking time and buzzgroups, can improve generic methods of small grouplearning. Attention to the dynamic of the group is important. The socio-emotional well being of the group is important for success in the task of the group. Although there are changes in technology, developingdiscussion and cognitive skills remains a priority. The effectiveness of small group learning sessions canbe improved by observing the processes of groupinteraction.Hence this Guide draws on the views of experts andpractitioners as well as the relevant research.Groups and their effectivenessBefore embarking upon the main topics, it might be useful toclarify what constitutes a group and a small group, the likelybenefits of small group learning and the effectiveness of smallgroup work.Strictly speaking, a collection of individuals is not a groupuntil they interact. In some forms of small group learning, theinteraction may be primarily with the tutor, as in some sessionsin basic sciences; the interaction may be predominantlyCorrespondence: S. Edmunds, Department of Psychology, University of Westminster, 309 Regent Street, London W1B 2UW, UK. Tel: 44 2079115000; fax: þ44 (0)207 911 5106; email: edmunds@westminster.ac.ukISSN 0142–159X print/ISSN 1466–187X online/10/090715–12 ß 2010 Informa UK Ltd.DOI: 10.3109/0142159X.2010.505454715
Med Teach Downloaded from informahealthcare.com by Cleveland Clinic multi-site (Florida) on 05/13/14For personal use only.S. Edmunds & G. Brownbetween the students with the tutor acting as the discussionguide, as in some sessions in ethics; the interaction may bewholly between the students, as in tutorless groups such as insome PBL sessions; or the group may be virtual, i.e. themembers of the group may communicate electronically andnot necessarily synchronously.What counts as a small group depends on the culturalcontext. In the UK, 6–8 is often regarded as a small group forlearning purposes ( Jaques 2003; Exley & Dennick 2004;McCrorie 2006). As a group increases in size, the potentialresources of knowledge increase but the opportunity forinteraction decreases. Below a group size of four, leadership isusually shared between the members; over 12, well-definedleadership is needed; over 20, strong leadership is needed.Early work by Bales et al. (1951) suggested that a group ofthree or four was best for developing critical thinking anddecision making. Such small groups are not possible in mostmedical schools: one has to work with the groups one is given.However as indicated in this Guide, one can split the largegroup into smaller groups and so gain many of the benefits ofsmall group work.These benefits include the development of discussion skillsand thinking, exploration of attitudes and sharing and reflecting upon experiences. The latter are sometimes neglected insmall group sessions but they are important for the development of attitudes towards tasks and patients and sometimes forthe personal well-being of the students. The extent to whichthese benefits are gained in small groups is, of course,dependent upon the skills of the tutor and the students.Broadly speaking, small groups are better than large groups atpromoting thought and developing attitudes and values, andas effective, but not as efficient, as large group teaching, atimparting information (Bligh 2000). However it would bewrong to assume that all small groups are superior to all largegroups for these tasks. The size of the group may not be asimportant as what the group does. Studies suggest that smallgroups used in PBL are superior to other forms of teaching atdeveloping critical thinking (Schmidt 1998; Davis & Harden1999; Norman & Schmidt 2000; Wood 2003). These results maybe due to the well-defined structure of the tasks in PBL.However some of the evidence in favour of PBL is questionable on methodological grounds (Colliver & Markwell 2007;Newman n.d.). Furthermore, PBL can be done badly anddidactic teaching can be done well. So differences in methodare not the whole story. We suggest that skills, not methods,are the key to the effectiveness of small group learning.Skills of small group learningThe core discussion skills of small group learning arequestioning, listening, responding and explaining. Theseskills provide the basis for the development of teamworkand collaborative learning. In the longer term they can aid thedevelopment of communication competency with patients andcolleagues.Preparation by both tutor and students, and openings andending by the tutor are also important. Most important of all forthe tutor is the meta-skill of knowing when to use a discussionskill. All the above discussion skills can facilitate thinking.716Discussion skills of tutorCognitive skills of studentsand studentsAsking questionsGaining understandingListeningCritical thinkingRespondingReasoningExplainingCan lead toProblem solvingOpening and closingDecision makingPreparationCreative thinkingFigure 1. Discussion can lead to thinking.In other words, discussion skills can develop cognitive skills.Figure 1 summarises the skills of discussion and thinking.Asking questionsQuestions have a number of functions in small group learningsituations: to arouse interest and curiosity in a topic, to assessthe extent of the students’ knowledge; and to encouragecritical thought and evaluation. Skilfully used questions are ‘apotent device for initiating, sustaining and directing conversation’ (Dickson & Hargie 2004, p. 121). Effective questioningrelies on effective listening and responding but it is convenientto consider questioning separately as it is complex and a keyskill within small group learning.There are numerous types of question. Classifying theseinto subtypes is a useful way to start thinking about whichquestions to use in which situation and several differenttypologies have been put forward (see, e.g. Brown & Atkins1988; Bligh 2000; Dickson & Hargie 2004; Brookfield & Preskill2005; Watts & Pedrusa 2006). Brown and Atkins used thefollowing dimensional classification approach which theysuggested was useful for enabling effective teaching:narrow–broad; recall–thought; confused–clear; and encouraging–threatening. These dimensions are elaborated on below.Narrow–broadNarrow questions typically request a brief, factual responseand have a correct answer. They allow the tutor to control thediscussion but if used too frequently can inhibit discussion.Broad questions on the other hand tend to require a morewide ranging answer and can be answered in a number ofdifferent ways, they frequently start with the words ‘why’,‘what’ and ‘how’. Broad questions are more likely to provokethe in-depth expression of opinions, attitudes and feelings thannarrow questions (Dickson & Hargie 2004). They also allowthe students more control over the content of the discussion.Sometimes a tutor will pose a broad question when he actuallywants a specific response and will go on to reject students’responses until the desired one is given. Bligh (2000, p. 243)describes this as a game of ‘guess what I’m thinking’ andadvises that it can be very de-motivational for students.Instead, although it is challenging, tutors should try to acceptresponses to broad questions and build on these. Whenanswers are clearly wrong, it is still good practice to focus on
Effective small group learningthem, at least briefly, and empathise with the students beforere-posing the question (Bligh 2000). The terms closed andopen questions are also sometimes used to refer to thisdimension.Med Teach Downloaded from informahealthcare.com by Cleveland Clinic multi-site (Florida) on 05/13/14For personal use only.Recall-observation–thoughtBloom (1956), (see also Anderson & Kratwohl 2001) identifiedsix cognitive levels of questioning which vary from recall ofpreviously learnt facts through to giving opinions and makingjudgements about the validity and quality of ideas. Recallquestions can be useful at the start of a discussion to assessknowledge and to start the thinking processes of students.It has long been known that higher level cognitive questionslead to greater achievement (Redfield & Rousseau 1981). Butthese types of questions are used only for about 20% of thetime in classrooms (Gall 1984). They are probably used lessfrequently than one might expect in seminars and tutorials.This might partly be due to tutors expecting questions to arisespontaneously during discussion, but as Brown and Atkins(1988, p. 71) suggest ‘. . . if we want to ask questions that getstudents thinking then we have to think about the questionswe are going to ask’.Questions which direct observation are particularly important in medicine but little attention has been given to the use ofthese sorts of questions. The increasing use of mini-clinicalevaluation exercise (CEX) and other methods of observation(Norcini & Burch 2007) may prompt research in this area.Box 1. Examples of probing questions. Which?Why?You say it is an X. What kind of an X?Does that always apply?How is that relevant?Can you give me an example?What alternative approach have you considered?How reliable is the evidence?Could you provide more detail on that?What are the underlying principles?So what problems did you encounter?What are the essential differences between the old and newprocedure?Note: Based on Brown and Atkins (1988).of a vital organ. So is the perfusion of the liver, the spleen, theheart, the brain . . . .?’ProbesThe same question can be asked in a number of different wayswhich either encourage or inhibit student responses. Youshould generally try to adopt an encouraging style of questioning in order to facilitate discussion. This is not to say thatthe questions you ask should be easy, rather be aware offactors such as tone of voice, stance and phrasing that canmake the difference between an intellectually difficult questionbeing perceived as threatening or challenging.Two further question types which are useful in small groupsettings are prompts and probes. These are supplementaryfollow up questions which ask a student to clarify an answer orprovide more information. Typically prompts contain hints andprobes contain challenges.These are a way of encouraging students to respond in moredepth about the topic being discussed; they can often stimulatethinking. Brookfield and Preskill (2005) suggest probingquestions can be used to ask for more evidence, e.g.: ‘Whatevidence is that claim based on?’, ‘What does the author saythat supports your argument?’ They can also ask for clarification, e.g.: ‘Can you give me an example?’, ‘Does that alwaysapply?’, ‘Is there an alternative viewpoint?’ Linking or extensionquestions can be used to encourage students to build on oneanother’s responses, e.g. ‘Is there any connection betweenwhat you have just said and what Jenny said earlier?’, ‘Doesyour comment support or challenge what we seem to besaying?’, ‘How does that contribution add to what has alreadybeen said?’ These probes can be useful to help students see thediscussion as a coherent and collaborative exercise in whicheach participant contributes something to a whole. A set ofprobing questions which have been found useful to promptthinking in small group learning in medicine is given in Box 1.In preparing to lead a small group learning session, it ishelpful to prepare the questions you will ask. This is often anoverlooked part of preparation. Plan to use a mixture ofquestion types and think about the sequence of questions youintend to ask. However, once you have your plan, be preparedto change it as the discussion proceeds and if you feel it isappropriate, change the order of your plan or abandonprepared questions for new ones made up on the spot. Furthersuggestions are given in the section on preparation. You mightalso consider ways in which you can encourage studentsto ask apposite questions. A brief session on types andpurposes of questioning can develop understanding(Rosenshine et al. 1996).PromptsListeningThese are useful as a way of giving hints, supplementaryinformation, or in some way leading the students to giveacceptable answers when the initial response to a questionwas not satisfactory (Bligh 2000). ‘OK, it is due to the perfusionIt is very important to listen well to what is said during smallgroup discussions, try to hear the explicit and underlyingimplicit meanings of what is said. All members of the grouphave a responsibility to listen, but the tutor has a specialConfused–clearClear questions tend to be brief, direct and firmly anchored incontext. Confusion can result from questions that are embedded within a number of additional statements or when thecontext of a question is not clear. Asking two or morequestions may also cause confusion.Encouraging–threatening717
S. Edmunds & G. BrownBox 2. Levels of d Teach Downloaded from informahealthcare.com by Cleveland Clinic multi-site (Florida) on 05/13/14For personal use only.StudyingDescriptionListening very casually; used unintentionally when one istired or distractedListening to obtain the outline. Often necessary when theparticipant is giving too much detailCategorising the contentsListening for particular content e.g. ‘Did the student mentiontaking the BP?’Going beyond the content to possible personal significance.Often tone of voice and facial expression indicates theremay be hidden meaningsresponsibility for retention of what has been said so that theycan recall this at appropriate times to help the studentsremember and see how ideas are linked. Doing this canincrease continuity in the discussion (Brookfield & Preskill2005). Such retention is not easy, but it helps if you allowstudents to be at the centre of the discussion so that you canfocus simply on what is being said without using cognitiveresources to plan your next question. Box 2 summarisesdifferent levels of listening.RespondingResponding to student comments in a way which encouragesdiscussion is a difficult skill to learn. A general point to keep inmind is to be as encouraging as possible. Students are oftennervous about speaking out in a group and, by being positiveabout responses, the tutor can develop an atmosphere wherestudents feel safe to answer without fear of being criticised andthis will facilitate the discussion (Hattie & Timperley 2007).It may seem more difficult to respond positively when ananswer is incorrect but it is still possible to thank the studentfor their contribution. If you feel it is appropriate, then confrontthe student with possible flaws in the answer (but not thestudent!).Often a tutor’s response may take the form of a furtherquestion, but there are other effective responses too which canbe used when the tutor wishes to leave control of thediscussion with the students. These responses include: reflecting back; perception checking; paraphrasing; and silence.Reflecting or saying back to a person what he or she has justsaid to you is a method which is used in counselling toencourage elaboration. In small group learning, reflecting backallows tutors to show the students they have been listening towhat has been said whilst leaving the agenda of discussionwith the student (Bligh 2000). Perception checking involvesthe tutor checking his or her understanding of what the studentmeant by using phrases like: ‘What I think you’re sayingis . . . . . . ’, ‘So what you’re saying is . . . .’. This can be useful tohelp the students clarify their thoughts more accurately. If theycorrect their tutor’s perception then they are analysing anddistinguishing their thoughts from those of their tutor (Bligh2000). The approach can be particularly useful when discussing complex ideas; it increases understanding, and theconfidence that arises from this can encourage more students718to participate in the discussion. Paraphrasing is similar toreflecting back but the tutor uses his or her own words. Thisapproach can help to make the discussion more precise. Forexample, the tutor can rephrase the comment using theappropriate technical term. ‘OK. So you think it is a renaltumour which requires nephrectomy?’Silence during a group discussion is something that makesmany tutors feel uncomfortable and there is a tendency torespond to students’ comments without hesitation in order toavoid such situations. However, silence can be a constructive,positive aspect of discussion (Brookfield & Preskill 2005) andit has been shown to increase student learning (Dillon 1994).It gives students time to reflect, to thi
the tutor is the meta-skill of knowing when to use a discussion skill. All the above discussion skills can facilitate thinking. In other words, discussion skills can develop cognitive skills. Figure 1 summarises the skills of discussion and thinking. Asking questions Questions hav
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