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Medical Teacher, Vol. 18, N o. 3, 1996

Twelve tips for effectivesmall-group teaching in the health

f . 0proIessionsYVONNE STEINERTDepartment of Family Medicine, Sir Mortimer B.Davis Jewish General Hospital and McGill University, Montreal, Canada

Small-group tutorials and discussion groups are commonlyused teaching method in the health professions (Barrows,1988; DeVaul e t ul., 1994; Kaufman, 1985; Kendrick &Freeling, 1993; Self et al . , 1993; Thomas, 1990). Small-group teaching offers students [l] an opportunity to dis-cuss and refine their understanding of complex issues, toproblem solve and apply their knowledge to new situations,and to reflect on their attitudes and feelings.

However, although small-group teaching offers manyadvantages, it also poses certain limitations. Teaching insmall groups can be more costly because it requires ahigher teacher-student ratio; small groups can easily bemisused and can, therefore, become inappropriate; andsome teachers find small-group teaching difficult-if notalien to them. As Jason & Westberg (1982) have said,small-group meetings can be lively, constructive interac-tions among students and teachers; however, in the handsof teachers who see themselves as purveyors of infor-mation-and not group facilitators-small group sessionscan become one-way, didactic. lecture-like events.

The goal of this article is to outline ways in whichsmall-group teaching can become more effective and moreenjoyable, and to recommend strategies for enhancingsmall-group teaching, whether you are working with thesame group over time or whether you are meeting with aparticular group only once (see Table 1).

Tip 1: Plan aheadAlthough much of small-group teaching occurs sponta-neously, it is important to plan ahead. As Rotem &Manzie(1980) have stated, careful planning is needed so thatsmall-group teaching sessions do not become open-ended,unintentional interactions. Small-group leaders need toconsider the many uses of small groups, formulate clearobjectives and teaching methods, and determine the ap-propriate group size and physical setting.

Consider the many uses of small groupsThe overriding goals of small-group teaching are to pro-mote understanding, critical thinking and problem solving,

to enhance communication skills and to foster self-directedlearning. Make sure that your teaching method matchesyour goals and objectives. For example, if your goal is totransmit new information, small-group teaching may notbe your method of choice. If, on the other hand, you wishto promote comprehension or application of previouslyacquired information, it will be. In planning ahead, con-sider the many uses of small groups, and remember thatthe goals of small-group teaching are both educational andsocial (Newble & Cannon, 1983).

Table 1 . Outline of the 12 tips.1.

2.

3 .4.5 .

6.7.8.9.

10.11.12.

Plan ahead:0 consider the many uses of small groups

formulate clear objectives and a possible map for theteaching sessiondetermine group size and arrange the physical facili-ties

Convene the group and develop a mutually acceptableagenda:

introduce group members to each other0 assess student needs and expectations0 develop a group agendaCreate a positive atmosphere for learningFocus the group on the task at handPromote individual involvement and active partici-pation:

question effectivelylisten attentively

0 reinforce student contributionsVary the teaching methodsProvide relevant information and respond appropriatelyObserve and clarify group processWork to overcome commonly encountered problemsSynthesize and summarize the group discussionEvaluate the session and plan for follow-upEnjoy yourself and have fun!

~~ ~ ~

Correspondence Dr Yvonne Steinert, Herzl Family Pracuce Center, SirMortimer B Dams Jewsh General Hospital, 5757 Legare Street, Montreal,Quebec H3T 126

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A number of studies have compared small-group teach- Tip 3: Create a positive atmosphere for learninging with more traditional large-group lectures. The ma-jority of these studies have shown that small groups are notconsidered more effective on measures of information re-call (Cox & Jaques, 1976). They do, however, promotemore favorable attitudes toward learning (Walton, 1968),increase comprehension, problem solving and the transferof knowledge to new situations (McKeachie, 1986) andallow for working on non-cognitive issues (Schwenk &Whitman, 1987).

Formulate clear objectives and a possible map or the teachingsessionOnce you have decided that small groups are your methodof choice, try to determine the students needs and expec-tations as well as previous learning experiences so that youcan target your teaching material appropriately. Formulateyour objectives and teaching strategies based on yourknowledge of the students and the content to be taught.Try to make your session stimulating, interesting andinformative.

Determine group size and arrange the physical facilitiesWhenever possible, consider group size. A group of 20 isnot a small group. Most educators settle on an optimal sizeof six to 10 members (Rotem & Manzie, 1980), though agroup of 10 or 12 may work, depending on the task athand.

Another important, but often ignored, consideration inplanning ahead is the physical setting where the teachingwill occur. What type of room will best suit your discussiongroup? Choose a meeting place that will facilitate studentinteraction and that will allow for an active exchange ofinformation. An amphitheatre designed for 200 students isclearly not appropriate. In addition to choosing the rightroom, it is also important to arrange the facilities before-hand. I do not believe that I have ever conducted asmall-group teaching session without moving the furniturearound!

Tip 2: Convene the group and develop a mutuallyacceptable agendaT o start the session, it is important to introduce yourselfand the group members to each other, and to assess theirgoals and expectations. Although this step is often takenfor granted, it is essential for promoting group cohesionand for accomplishing the task at hand. In many ways, thefirst 10 minutes of a small-group teaching session are themost critical to success; they set the stage for the work tobe done.

In convening the group, it is also important to outlinethe task a t hand, the available time for discussion, andproposed ways of achieving the groups goals. Wheneverpossible, try to incorporate the students goals and expec-tations into the plan for the teaching session, and developa group agenda. One of the most common reasons forfailure in small-group settings is the lack of clear goals andobjectives (Mayo et al., 1993). Make sure that you do notomit this very important first step.

One of the strengths of small-group teaching is the oppor-tunity for information exchange and group problem-solving. T o accomplish this objective, students must feelcomfortable enough to take risks, to expose their areas ofweakness, and to share their areas of expertise. For this tohappen, an atmosphere of mutual trust, respect and sup-port among the group members is essential.Try, therefore, to establish a non-threatening, relaxedenvironment orientated towards learning. Demonstrate re-spect for the group members, support individual contribu-tions, and emphasize group cooperation and teamwork.

Tip 4: Focus the group on the task at handAs has been previously stated, one of the most commonproblems in small-group teaching sessions is a lack of cleargoals and a lack of progress towards these goals. Through-out your session, make sure that the groups aims areexplicit and that the issues under consideration are clear.Carefully direct the discussion toward the intended goal,recognize irrelevant exchanges, and cut off longwinded andinappropriate contributions. For many health care profes-sionals, this is one of the most difficult tasks in a smallgroup. Accustomed to listening to patients, it is oftendifficult to cut people off.

It is also important to help the group to identify themain issues under discussion and to formulate key areasfor further study. Encourage the group to analyze theparticular topic or problem at hand, to suggest possibleexplanations and hypotheses, to seek relevant data, toevaluate alternative solutions and strategies, and to synthe-size the available information.

Finally, remember that the group leaders main role isto stimulate and guide discussion. Throughout your dis-cussion, remind the group of what remains to be done inthe available time and help group members to pace them-selves and to stay on track. Moreover, whenever possible,try to share responsibility for the success of the groupdiscussion with the students.

Tip 5: Promote individual involvement and activeparticipationOne of the strengths of small-group teaching is the oppor-tunity for students to become actively involved in theprocess of learning. Teachers can consider a number ofstrategies to promote individual involvement and activeparticipation. These include: effective questioning, activelistening and the reinforcement of individual contributions.

Question eflectivelyT o involve the group participants, request relevant facts,information and opinions. Question effectively to promotecritical thinking, problem solving and active participation(Foley & Smilansky, 1980; McKeachie, 1986; Schwenk&Whitman, 1987). Clarify ideas to ensure that they areunderstood by the group and pose questions which areprobing, prompting, analytic and stimulating. Avoid lec-turing or telling students what they should think. Redirect

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Twelve tips for effective small-group teaching

questions from yourself to the group. Remember that thedefinition of small group teaching is not a lecture in a smallSOUP.

Listen attentivelyAt the same time, listen attentively. One of the mostcommonly observed problems in small groups is theteachers tendency to talk too much. Encourage groupmembers to talk to each other rather than to you, thegroup leader, and allow participants to state their ownopinions, thoughts and suggestions.

Reinforce student contributionsRecognize individual contributions and reinforce appro-priately. Provide feedback to students and encourage con-structive feedback among the group members. The pro-vision of feedback has been identified by students as one ofthe most important characteristics of effective tutors(Mayo et al., 1993) and yet it is often omitted in theteaching process. Provide relevant and accurate feedbackwhenever possible.

To promote individual learning, make sure that allstudents participate in the discussion. Do not focus on oneparticular student or allow one student to monopolize thediscussion. Try to overcome uneven participation bydrawing out the shy or reluctant student. At the same time,make sure that you do not become the center of attentionfor the students. Encourage students to talk to each otherand to share responsibility for the success of the group.Teachers often look at the level of participation amongthe students as the measure of success. Remember that thisis only one criterion. Groups must also accomplish the taskat hand in order to be considered successful.

Tip 6: Vary the teaching methodsStudents attention frequently wanders; they present withdifferent learning styles; and they need to be interested inorder to be involved. The same applies to teachers. When-ever possible, try to vary your teaching methods and con-sider different options to keep students interested andinvolved (see Habeshaw, et al., 1984; Handfield-Jones etal., 1993). The small-group setting allows for the use of avariety of teaching methods and activities, the most com-mon of which include the following.

Clinical casesThe use of clinical cases has long been a hallmark insmall-group teaching, and they can be used in a variety ofways: to illustrate a particular problem; to encourage stu-dents to work independently; to promote problem solving;and to demonstrate the clinical practice of medicine.

Student presentationsStudent presentations may be used creatively to encourageself-directed learning. However, to avoid students givinglectures, they, too, must be told what is expected of them.Help students to become effective communicators, to be

organized in their presentations, to speak clearly and to useappropriate audiovisual materials. Developing writtenguidelines for expected student behaviour may also behelpful in this context.

Role plays and simulationsRole plays and simulations can also be used effectively insmall groups to promote skill acquisition and to helpstudents develop solutions to a problem, try out newbehaviours and receive feedback (Simpson, 1985). Be-cause role plays generally provoke less anxiety than real-lifesituations, students may be able to use newly acquiredskills more easily and att end t o what is going on with fewerdistractions and concerns (see Steinert, 1993a).

Films and videotapesFilms and videotapes are excellent triggers for discussionand can serve to stimulate interest in a particular topic orprovide examples for further reflection. Videotapes canalso be used to facilitate self-assessment, skill acquisitionand increased understanding and empathy (see Steinert,1993b).

Stud y guides an d handoutsAlthough infrequently used for this purpose, study guidesand handouts can help to encourage independent learningand problem solving. They can also be used to supplementthe course content (Laidlaw & Harden, 1990; Kroenke,1991) and can, therefore, allow for increased discussionand debate.

Short quizzesShort quizzes can provide feedback on knowledge acqui-sition and understanding of the material learned. They canalso help to provide a sense of rigor to an otherwisefree-floating or unstructured discussion. Conducting ashort quiz at the beginning of a small-group teachingsession has also been known to prevent late arrivals!

Tip 7: Provide relevantinformation and respond ap-propriatelyAlthough students should learn from each other, they alsowant to learn from the small-group facilitator. Share yourpersonal experiences with the s tudents and provide limitedbut relevant information. Build on the students responsesand add your own insights and knowledge. Ensure that allbasic material is covered and fill in any omissions. Clarifyconfusing issues and explain controversies. When appro-priate, provide clinical input or personal anecdotes toheighten the relevance of the topic under discussion.

Tip 8: Observe and clarify group processGroups are made up of individuals who interact with oneanother. As a result, the dynamics of the group cannot beunderstood by merely adding up the qualities of individual

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Y. teinert

members (Rotem & Manzie, 1980). This is one of thereasons why small-group teaching is so challenging!

Encouraging and maintaining effective interaction isalso one of the most difficult tasks facing group leaders.Group leaders must, at times, tu rn apathy and indifferenceinto involvement, use conflict constructively, prompt silentmembers into action and silence manipulative members.The skills to accomplish these objectives are complex.

To promote group functioning, recognize the groupmembers interactions, communication patterns and non-verbal behaviours. Identify shifts in mood, attitudes andparticipation. Observe signs of interest, disagreement andwillingness to contribute. Do not overlook cues indicatingrestlessness or boredom such as wiggling in seats, tappingfeet and clenched hands, and use these signs to guide theteaching session. If everyone in your group is falling asleep,it may be time to end the discussion.

Group members also play different roles (e.g. the taskmaster, the peace-keeper; the group clown). The nature ofthese roles and the identity of those who accept particularroles are affected by the groups process, goals and activi-ties, and external conditions (Hansen, 1972). Try to ac-knowledge the roles that group members have adopted anduse this information to help the group accomplish the taskat hand. For example, you might to want to identify theindividual with the most influence if the group needs tomake a difficult decision, or call upon the one who typi-cally helps the group deal with feelings when you have tofocus on a difficult task. An awareness of individual roles inthe group is important for both group harmony and taskaccomplishment.Although it is always important to observe group pro-cess, teachers may not always want to intervene. Fre-quently, however, it is helpful to identify what is happeningin the group, to assist group members in becoming awareof their own group dynamics and to alter particular pat-terns of behaviour. Whenever possible, enlist group mem-bers in your perceptions of the groups process and helpthem to understand the importance of monitoring thisdimension of group functioning. Remember that groupmembers need a sanction to address group issues andproblems. At the same time, help the group to deal withtension and conflict, and work on improving group mem-bers relationships with each other. Groups have to fulfilltwo major functions: task accomplishment and group har-mony. The first cannot be achieved without attention tothe second.

Tip 9: Work to overcome commonly encounteredproblemsSmall-group teachers face a number of common problems:how to start the discussion, how to deal with non-partici-pation, how to make progress towards the course objec-tives, how to work with difficult members and how tohandle group conflict (McKeachie, 1986). Althoughspecific strategies for intervention cannot be outlined here(see Tiberius, 1990), some general principles apply in mostsituations. Ask yourself why the particular problem is oc-curring, what you can do differently to overcome theproblem, and how responsibility for success can be sharedwith the students. Group problems usually stem from three

sources: unclear or unattainable goals; a lack of groupinteraction, either because the teacher is dominating orbecause of unequal participation by the members; or poorgroup motivation (Tiberius, 1990). Quickly identify theproblem and adopt strategies to either circumvent theproblem or deal with it appropriately. At times, labellingthe problem and sharing your perceptions may besufficient; at other times specific interventions are indi-cated (e.g. changing the physical space; addressing groupconflict; talking to a particular group member about his orher behaviour after the meeting).

Tip 10: Synthesize and summarize the group dis-cussionThroughout the session, pull together main issues, themesor points made. Highlight the links within the discussionand between the topics discussed and other topics. Synthe-size what has been said, putting together the group mem-bers contributions and moving the group ahead. At times,it may also be helpful to repeat statements made andparaphrase individual contributions, to build on the dis-cussion and to move on. Evaluate the students ideas,identifying possible flaws and problems which may arisefrom them.

A final summary is critical for closure. This summaryshould include the issues discussed, the problemsidentified and areas for further study. At times, the groupleader may wish to summarize the key points made for thegroup. At other times, it is helpful to go around the roomasking the students to summarize what they rememberfrom the discussion. A flip chart can be used effectively forthis purpose-and can leave students with a clear list ofwhat has been discussed. Asking students to summarizethe discussion also helps the teacher t o evaluate the successof the session. Make sure to leave adequate time for thisimportant, but often overlooked, step, as it is essential inproviding a sense of accomplishment.

Tip 11: Evaluate the session and plan for follow-upThroughout the discussion, t r y to monitor student prog-ress and encourage constructive feedback within the group.In addition, evaluate the group discussion and task accom-plishment, together with the group and on your own. Tryto foster dialogue about group functioning and task accom-plishment, and solicit feedback on your own performance.Pre-existing tutor evaluation forms (Dolmans et al., 1994;Mayo et al . , 1993; Thompson, 1985) may also be used tostructure student feedback on teacher performance and tohighlight areas for improvement. Finally, do not forgethousekeeping chores (e.g. attendance; course deadlines),and plan for the next meeting.

Tip 12: Enjoy yourself and have funSmall groups afford an excellent opportunity for role mod-elling and increasing motivation for learning. Studentsquickly pick up on the teachers enthusiasm and interest. Ifyou do not enjoy working in small groups, your chances ofsuccess with this teaching format will be severely limited.Show your enthusiasm and your interest. As McKeachie

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(1986) has stated, if an instructor is enthusiastic, friendlyand obviously interested in the subject, the students willgenerally follow suit.

AcknowledgementsI would like to thank Dr Louise Nasmith, Ms NormaDaigle and the members of the Faculty DevelopmentCommittee of the Department of Family Medicine fortheir participation in the development of these guidelines.I would also like to thank Drs Peter McLeod and LarryConochie for helping us to refme these concepts, and thefaculty members who have attended our workshops on'Small Group Teaching', for their constructive feedbackand invaluable contributions as small group participants.

Note on contributorYVONNESTEINERT, clinical psychologist and Associate Professorof Family Medicine, is the Director of Behavioural Sciences at theHen1 Family Practice Center of the Sir Mortimer B. Davis JewishGeneral Hospital and the Director of Faculty Development in theDepartment of Family Medicine at McGill University. She is alsothe Associate Dean for Faculty Development in the Faculty ofMedicine at McGill University, Montreal, Quebec.

Note[l] Please note that the word student will be used throughout this

discussion to denote a student at any level of the educationalsystem in the health professions, be it an undergraduate medicalor nursing student, a resident or member of housestaff, a CMEparticipant or any other adult learner.

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