Incorporating Problem-Based Learning and Video Technology in Teaching Group Process in an Occupational Therapy Curriculum

Schaber, Patricia L

This paper describes an innovative, cost-effective method for teaching group dynamics in an occupational therapy curriculum. The revised "Models of Group Dynamics" course incorporated problem-based learning (PBL) sessions and video technology. In this single-semester course, the class of 24 students was divided into small groups of five to seven students. Each group participated in six hours of PBL sessions and six hours of observation. PBL effectively served as the instructional methodology to stimulate group dynamics because it demands that the students engage in the group process by creating an open structure for discussion, negotiating goals, and building team consensus in the group. The PBL experience facilitated the integration of the various content areas of the curriculum by expecting the student to apply previous learning to the construction of a therapeutic treatment plan. Through the use of a closed-circuit video monitor, students in the observation group analyzed group process skills in real time without interruption. This format provided the opportunity for students to generate feedback responses about group process with faculty guidance. The use of a closed-circuit video monitor was a low-cost, effective tool that facilitated the learning process. Measures of student learning indicated that the new course design was effective in meeting course objectives. Measures of the effectiveness of the new course design included focus groups conducted in two time periods: after completion of the course and after completion of fieldwork. The results demonstrated that the course had continuing impact on group skills carried into the fieldwork experience. J Allied Health 2005; 34:110-116.

THE SKILLS to participate effectively as members of interprofessional teams are paramount for today's heath care providers.1 Proficiency in interpersonal communication and group facilitation is vital not only with team membership but also with the increasing demands to lead client educational and support groups. The expectation for graduate students in professional programs is that group communication skills are developed in the classroom setting.1-3 The challenge for health care educators is to design curricula and learning activities in which students can develop competence in group process skills while in an academic environment, anticipating that those skills will effectively transfer to the clinical environment.4 The premise of this paper is that through creative learning activities, the constraints of the classroom setting do not have to limit preparation of students to perform successfully in the clinic.

This paper describes an innovative, cost-effective instructional methodology that was incorporated into the revision of the "Models of Group Dynamics" course in an occupational therapy curriculum. The uniqueness of this method was the incorporation of problem-based learning (PBL) and video technology in facilitated small-group sessions within a one-semester academic course. Student competence in attaining the course objectives was evaluated by objective testing and a short student essay. A qualitative evaluation of the new course design was conducted by analyzing transcribed text from focus groups in two time periods. The purpose of the focus groups was to determine if group process skills were effectively developed through participation in the course and if these skills transferred into clinical practice in fieldwork.

Significance

Recent changes in health care delivery increased the demand for effective group skills in interprofessional health care teams. The emphasis on community service delivery has moved health services into the home and community, increasing interaction with families and a fluid health care team.5 Adhering to legal mandates, schools have expanded the use of team decision making in adjusting therapy services to comply with the Individual Education Plan.6 The Individual and Family Service Plan brings county and school services together in a family-centered care model demanding skilled communication among an array of professionals and family members.6 With the increase in the aging population, care models designed to serve clients with chronic disease are emerging with team service delivery as a central element in the model.7,8

For many allied health care curriculums, the move to master's- and doctoral-level preparation and the corresponding compensation that follows invites the therapist to work in administrative positions in which group skills are foundational to good management.9 Therapeutic interventions and fieldwork training using a group approach rather than the traditional individual approach are being tested as cost-containment measures.10 The health care professional's impact is contingent on effective group process skills in every arena.

Course Design Framework

ACTIVE LEARNING

Higher education affirms "active" learning as the new paradigm, which promotes interdependence in teaching and learning.11,12 According to Campbell and Smith, the stimulus for active learning is creative controversy and reflection with teacher and student processing together.13 This approach to teaching and learning is dependent on effective group process skills for both student and instructor.14,15 For the past three decades, through extensive studies of student learning in higher education, Johnson et al.12 have developed a framework for active learning in the college classroom. Their conclusions are as follows:

Compared with concurrence-seeking, debate, and individ' ualistic efforts, controversy results in greater mastery and retention of the subject matter, higher quality problem solving, greater creativity in thinking, greater motivation to learn more about the topic, more productive exchange of expertise among group members, greater task involvement, more positive relationships among group members, more accurate perspective taking, and higher self-esteem. In addition, students enjoy it more.

This paradigm provided a framework for the course design revision of "Models of Group Dynamics." Many of the elements of active classroom learning were stimulated in the PBL sessions that served as the impetus to generate controversy, spark creativity, and improve task involvement.

PBL

PBL is where the problem, or case, is central, the learning is student initiated, and the desired outcome moves toward development of a treatment approach.16-18 It challenges students to integrate vertically the basic science information with clinical practice. The group identifies the facts based on existing knowledge from the case, generates hypotheses, and formulates questions that fall into two categories: unanswered questions (those with unknown information about the case) and learning issues (those the student can investigate and bring new information about the case). As students wrestle with the case, more information is added and the process repeats itself until the students are satisfied with the treatment plan (see Figure 1). A faculty facilitator guides the PBL sessions initially and gradually withdraws from the leadership role as the students gain confidence in guiding their own process. Student interaction and controversy are stimulated by the student-generated structuring of the PBL session. Students, in a safe and guided learning environment, can try on new behavioral strategies and experience the outcomes, whether they hinder or enhance group process.

PBL has been successfully used in health care curriculums for the purpose of applying course content to real patient cases in preparation for clinical practice.19,20 It is designed to use patient cues as the starting point of intervention, develop clinical reasoning processes, and promote self-directed learning. While PBL has been touted as an effective method that has the potential to develop group process skills, it has not been selected as an instructional methodology specifically for the purpose of training students in analysis and facilitation of group dynamics.

Group process skill training is traditionally taught incorporating small-group communication topics with in-class experiential exercises. For instance, students learn about problem-solving strategies and then participate in an exercise in problem solving such as the "stranded in the desert situation."21 Before revising the course, students reported that the applied exercises seem contrived and the content common sense. Students mentioned that they relied more on their past experience in groups or "what felt comfortable" rather than applying new behaviors to alter group process. They reported that when they were assigned to facilitate an in-class activity, they were at a loss in structuring the group process, initiating the interaction, and formulating effective feedback. The new design aimed specifically at developing these skills.

Method of Instruction

"Models of Group Dynamics," a two-credit course, met four hours per week for a 15-week semester. It was redesigned with the infusion of PBL sessions, observed and analyzed in real time using a closed-circuit video system (see the Appendix for course content and schedule). This "laboratory" experience gave the students the opportunity to apply approaches in altering group process in a mentored environment. It required the students to formulate and provide feedback on group behaviors.

A key assumption of the course design was that understanding small-group theory preceded application, analysis, and evaluation.22 With this in mind, the course was divided into two portions. The first eight weeks was the didactic portion, where the topics were presented using a lecture/task format with the goal of mastering content such as group stage theory, leadership, power, decision making, and so on. The second seven weeks, the laboratory portion, consisted of rotating groups of five to seven students through a PBL group and an observation group. The PBL group met for three sessions that were two hours per session. The observation group viewed the PBL group on a closed-circuit monitor in an adjacent room. All students participated in one PBL case (six hours total) and one observation group (six hours total) that were facilitated by course instructors. The PBL sessions were videotaped for review as a final evaluation so students could revisit the feedback from the observation group and analyze their role and behavior more objectively.

A second assumption of the course design was that self-analysis preceded and enhanced analysis of the group.23 The self-analysis experience included completing the personal assessment inventories Myers-Briggs Type Indicator24 and Gregorc Style Delineator.25 These are standardized tools that informed students of their own preferred approach in gathering and processing information (Myers-Briggs Type Indicator scales: extrovert-introvert, sensing-intuitive, feeling-thinking, perceiving-judging; Gregorc scales: concrete-abstract, random-sequential). Beyond identifying their own preferences, they gained an understanding of others' styles and how to effectively communicate with someone who thinks differently. The Myers-Briggs Type Indicator required certification for administration and interpretation, which was provided by campus student counseling services. A third assessment used was the Strength Deployment Inventory,26 a group assessment tool that focused on what motivated members of a group when all was going well (caring, authority, control) and how members changed behavior in response to conflict (empathetic, assertive, cautious).

For the student, the self-analysis experience can be growth promoting yet personally threatening. Understanding one's own personal style in group interaction involves exposing the "blind area" or those behaviors that are unknown to oneself.27 Reflecting on those interactions that contribute to group effectiveness also brings into awareness those interactions that are barriers to group cohesion. Students became aware of how their own style of interaction impeded or stimulated effective group process and could try on new strategies for interaction.

A third assumption of the course design was that learning is most effective in real time with meaningful material.28 Students were motivated in the PBL sessions to apply the knowledge they had acquired in the curriculum to real cases that were designed to stimulate thinking at a level that was challenging yet allowed for success.29,30 The observation group was provided with an outline of the topic areas covered in the didactic portion of the course. Each observation group member selected a topic (e.g., "power and leadership") and, with review notes in hand, prepared feedhack for the PBL group on that topic. The observation group was trained to provide feedback by describing the group member's behavior objectively and contrasting the events with the course content to explain and predict the group process. The observation group could discuss confidentially what was occurring in the PBL group in a safe and mentored environment.

After the six hours of PBL were completed, a video review session was held with the PBL group to discuss the feedback in relation to their recollections of the experience. This session was designed to be lighthearted and to relieve tensions, as students were encouraged to discuss their strengths and barriers to effective group membership. It was designed to serve as a healthy closure to a process that had emotional investment.

A logistical barrier was the cost of equipping a closedcircuit classroom. A one-way mirror with auditory amplification would have been ideal but was cost prohibitive. A video camera, tripod, and monitor were part of the existing inventory. The rooms were wired at no cost by passing a connecting cable through the electrical wall outlet. It was important that any discussion of group process occurred in the observation room freely, confidentially, and concurrently with the PBL sessions.

Method of Evaluation

EVALUATING COURSE OBJECTIVES

The primary objectives of the course were to demonstrate keen observational skills in identifying and analyzing group dynamics and to synthesize knowledge of group process and personal skill identification to increase group effectiveness. Assessment of student learning in comprehension, evaluation, and synthesis of course content was measured by two scores: an 80-point objective test given at the conclusion of the didactic portion of the course and an individual student essay, five to seven pages, submitted after the conclusion of the experiential portion of the course. Competence in meeting the course objectives was determined by a passing grade in these two measures.

RESULTS OF EVALUATION OF COURSE OBJECTIVES

All 24 students demonstrated skill attainment in these objectives. The grading criteria for individual papers scored the degree of synthesis of course content to the analysis of group process and the degree the student effectively captured an understanding of self in relation to the group process. Overall, in the essays, the students appeared to emphasize the skills pertaining to their own self-awareness of personal interactional styles that affected the group process. Students demonstrated ease in discussing their own style. For instance, one student admitted, "It takes a person a while to adjust to my style of communication. It would likely be a good idea (for me) to increase positive-ness and decrease my negativity so I don't affect the group morale." Another student reported in her essay, "I noticed that as an extrovert, I do think out loud and that I sometimes do this well and at other times I do not. I was more aware of it in this group than in other groups."

EVALUATING COURSE DESIGN

The main goal of the group dynamics course was to produce students who could function effectively as members of interprofessional teams. Evaluation of the course design was targeted to measure the performance outcomes, or those implicit, intangible skills needed to be effective in a group with the transferability of those skills into clinical practice. Was the course design effective in preparing students to act with confidence using skills and strategies to intervene and facilitate group process? And were those skills carried into the fieId work experience?

MEASURE OF EVALUATION OF COURSE DESIGN

To evaluate the effectiveness of the course design in meeting performance outcomes carried into clinical performance, two focus groups of four students each were conducted in April 2002. Each group of students represented a different point in time in the curriculum. The first group had completed the course the prior semester (time 1) and the second group had completed the course the prior year and had completed their six months of clinical fieldwork the prior semester (time 2). The sample was purposive in that all students with experience with the new course design were solicited. All students who voluntarily responded were included in the focus groups based on their availability at the time.

The stimulus for the focus groups included the openended question, "Through your participation in the course 'Models of Group Dynamics,' what knowledge and skills did you develop in group process?"

METHOD OF ANALYSIS

The audiotaped focus groups were transcribed using an abridged method, where transcriptions included all material pertinent to the topic.31 The text was read and reread until themes emerged. The text was then coded to note the presence of words and phrases that supported the themes in three areas. A negative analysis was conducted that looked at portions of the text that appeared outside of the three areas being examined to determine if learning occurred beyond what was intended and anticipated.

THEMES

The qualitative data from two focus groups revealed three themes that emerged from the transcribed text. The analysis revealed that the students, through participation in the "Models of Group Dynamics" course, exhibited an increased ability in understanding style, empowering self, and providing and receiving feedback.

Furthermore, contrasting the text from time 1 (shortly after the course) to time 2 (after fieldwork) indicated that the fieldwork experience contributed to a more advanced level of maturity in all areas of group work.

Understanding Style

The students reported a greater understanding of themselves, their communication style, and the effect these had on the group. Understanding differences appeared to instill a greater sense of confidence in interpersonal communication. Students demonstrated a propensity to apply the content of the course to their personal lives without making a conscious effort to do so. It was impressive that the language of small-group dynamics was incorporated readily into their daily conversation. The students talked frankly about tolerance of different interaction styles, group norms, stages of group process, and consciously allowing movement in the group.

R.S. -I was a lot better than [my supervisors], I mean this is a kind of a big statement, I took people's learning styles or different mannerisms, different ways into account a lot more than my supervisors did, and I don't know if it was because they been at it so long that they just, kind of, don't do that. . . .

They're kind of automatic in what they do or they just never learned that everybody has their own way of being and learning and everything like that. I think that was one of my stronger points-relating to the patient, making sure that they were understanding me.

B.N.-Understanding how you act in different situations is important too. It adds a little bit more objectivity to your behavior so you can say I'm in a situation so I have a tendency to do that, so you can ask [yourself] am I overreacting or do I need to do a little bit more of this so. ... They were more abstract random than I was. I find myself categorizing people and thinking this is my best way to approach them. Do I need to write it down on a note to keep track of what my question was? Approaching people was reflected by my learning.

H.S.-I thought a lot about being abstract random in a group full of people, like my first place I was in my supervisor was very organized, very concrete sequential. And for me to come in, I thought about that, just how she's so orderly and I just came in and tried to fit in with how she was and once a system is figured out. . . .

B.N.-Being able to recognize different styles of learning of different people. Even now I'll be studying and I'll be annoyed by what someone is doing and I'll think, oh yeah, she's an AR [abstract random] and that's the way she is, you know, because I definitely am a CS [concrete sequential]. Being open minded about the group process, just that everybody's not going to be the same way you are and that's OK, it can still work. You get more out of the process if you all aren't the same.

Empowering Self

The students strategized and implemented new behaviors to alter the direction a group was taking. If the group was headed in a direction that was ineffective, the students reported reflecting and strategizing before taking action in redirecting the process. They reported this occurring in their personal and their professional group experiences. They were able to try on a new role or incorporate a different structure to the group and evaluate the outcome of their decision. They described how their own behavior made a difference in the outcome of the group, and they expressed a confidence or sense of empowerment.

B.N.-One of the points in the course that came out is that you can make a difference in the relationship by just being different yourself. You know cause I always thought well, they're that way so I'm going to be this way and you know like you're giving your power away.

R.S. -People making a conscious effort to change how they were going to be and seeing what happened.

H.S.-Yeah. Haven't you ever found yourself doing that? Like with that impossible woman, I was trying to every day go in there with a different face like to see what was going to work. And then once I found something that would work I kind of stuck with it and it became easier.

B.N.-If you move out of your preferred comfort, because that's all that is, is a preferred comfort, if you move a little bit off of your scale or two of your scales, what happens? You don't have to move to the opposite extremes, you just move a little bit on your scales.

H.S.-Or if you're an introvert how are you going to deal with an extrovert? Or when you get mad and you clam up, how are you going to deal with an explosive mad person?

B.N.-And it's like, I don't like the way this situation is going so what one thing can I do that is different. When there's conflict I just want to say "good-bye" so I have to learn how to say, "ok."

H.S.-I like to take on a talking role and there was one day I thought, I'm just going to keep quiet see, you know, just to see what would change. It really clarified that the group process changes when different aspects change.

Providing and Receiving Feedback

The students noted that the group dynamics course experience was one of the few opportunities in higher education in which they were able to give and receive feedback. It was constructive criticism in a safe and guided environment.

B.K.-It was brought up in our group if you could wait until the end for feedback, because in our group it totally affected how we interacted after that. Cause I know I thought I am totally not going to laugh this time or touch my face...I think that's another good thing about the process, you learn how to take constructive criticism. We've never had any of that before which is missing. I think it's beneficial.

A.K.-We just get a grade. We don't get feedback. We get an anonymous thing like [a comment] for eye contact "good" but not anything specific.

VJ.-Feedback from the instructors was content based. We don't get personal feedback anywhere in the curriculum. If you're not being professional. . . .

B.K.-[In the PBL group] you would take the feedback and try to do it the next session. It means a lot more coming from your peers. We've never had to give feedback before. Giving it was just as hard. We've never had to do that except for a circle on a piece of paper.

Analysis of the text of the focus groups indicated that students at different time periods emphasized different aspects of their learning. Students in time 1 reported less enthusiasm about the skills gained through participation in the course made indirectly apparent by the amount of offtopic conversation in the focus group. They demonstrated skills in retaining and applying the course content to the group process, but their comments were disproportionately in reference to their personal life.

One year after course completion and with the experience of level II fieldwork training behind them, students seemed to demonstrate a renewed enthusiasm about the course, offering many examples of their learning as it applied to their clinical experience. The application in fieldwork of facilitating groups and strategizing ways to guide group process gave them new understanding of course material. Fieldwork training appeared to strengthen skills in observation and deepen the understanding of how one can intervene in group process effectively, and they reported a greater sense of confidence in group facilitation. The students also identified how a facilitator could alter the process by choosing a strategy for his or her own behavior. Providing clear feedback was the most challenging task reported in the student experience. It appeared that the students in time 2 were more willing to take a step back from the group, think about what was occurring, and strategize a return to the process to effect a changed outcome.

Discussion

The redesign of the group dynamics course was successful in providing students with an in-class learning experience that stimulated reflection on and development of group process skills. This ability to reflect on the group process as it was occurring and strategize a behavioral response concurs with the overall design of the curriculum based on Donald Schön's critical thinking model for the reflective practitioner.32 Reflection as a procedural element of practice was embedded in the researcher's conceptual framework. Reviewing the comments from the transcribed text demonstrated that the students reported a different emphasis on the learning experience from the completion of the course to one year later. What emerged was a learning continuum that supported assumptions of the course design: that knowledge of theory precedes application of content, that the students' mastery of personal traits and self-knowledge precedes group member effectiveness, and that learning deepens when applied in real practice.

In current occupational therapy education, the fieldwork component is an activity that bridges academic learning and applied learning.33 The results of this study support current practice in fieldwork education or clinical training where reflection is the means to deepen understanding of practice frameworks and models.34 Study results support the "applied" or "service" learning approach where the setting approximates or replicates future professional practice. While this redesign creates a simulated clinical setting and brings the student closer to clinical practice, there still remains a temporal and environmental gap between learning and practice ever present in professional career training.

Conclusions

This innovative design of a group dynamics course embodied higher education trends of teaching and learning.35 Learning was active, learning objectives were measured in behavioral terms, course design integrated technology, and the course design allowed for diversity of individual style in group interaction. Limitations of the study design include a small participant number for focus groups, a purposive sample that may bias the results favorably, and lack of control over group process skill development beyond participation in the course. Measuring course effectiveness in preparing students for professional practice is challenging for this reason. Future research in methods of teaching group skills for interprofessional teaming is needed, along with more sophisticated measurement of outcomes. This paper will hopefully stimulate more innovative attempts in teaching group dynamics in the preparation of future health care providers. Ideally, it will also expand the thinking around methods to evaluate course effectiveness over time for learning that continues beyond the confines of the classroom.

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Patricia L. Schaber, PhO, OTR/L

Ms. Schaber is Assistant Professor, Program in Occupational Therapy, University of Minnesota, Minneapolis, Minnesota.

Received December 6, 2002; revision accepted January 9, 2004.

Address correspondence and reprint requests to: Patricia L. Schaber, PhD, OTR/L, Program in Occupational Therapy, University of Minnesota, MMC 388, Minneapolis, MN 55455. Tel 612-626-5111; fax 612-625-7192; e-mail schab002@umn.edu.

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