Teaching Team Work and Cooperation: Critical Skills in Healthcare Today

by Matthew Levit, Doctor of Pharmacy Candidate, Class of 2018, University of Maryland School of Pharmacy

Traditional instructional models stress the importance of individualism, but many educators and schools have begun to emphasize cooperative learning methods.¹ Cooperative learning is an integrative learning model that seeks to educate students through activities that promote social learning and leadership experiences.^2,3 Cooperative learning has its origins in social interdependence theory. According to this theory, the learning outcomes of an individual are determined by their own actions as well as the actions of others.³ Cooperative learning builds on this theory by postulating that learning occurs best through social engagement.⁴

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Cooperative learning is more than just working together in a group. Students learn by using their social and interpersonal skills to achieve an academic goal.¹ Cooperative learning is commonly used in a variety of practice-based settings including service learning, integrative internships, and continuing education (CE) seminars.⁵ In some of these settings, students receive academic credit and solve real-world problems.⁵ For example, students rotating on an interprofessional team may encounter a patient that suffers from multiple comorbidities (e.g. diabetes, hypertension, and neuropathic pain). One student in the group may be adept at diabetes management.  Another may have experience managing patients with high blood pressure.  And another may be very knowledgeable about neuropathic pain. Collectively, the students learn from each other and are more likely to successfully complete the academic exercise.

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There are five key elements to the cooperative learning model. These include positive interdependence, individual and group accountability, face-to-face promotive interaction, interpersonal and small group skills, and group processing.^1,6 Positive interdependence requires that every member of the group value each other’s contributions.¹ Interprofessional healthcare teams must have positive interdependence in order to fully utilize each member’s unique contributions to the patient’s care. Individual and group accountability requires that each member of the group is accountable for one’s actions and all must contribute to the completion of the assigned task.⁶ An evaluator should discipline students who do not contribute because it is detrimental to the group’s overall success. Interpersonal and small group skills include effective leadership and communication, building trust, making clear decisions, and managing potential conflicts.¹ Face to face promotive interactions require learners to share resources as well as support and encourage their teammates success.⁶ Group processing requires communication among group members. Members should be encouraged to express any concerns they have with each other for the overall benefit of the group.⁶

One example of an instructional method that uses the five key elements of the cooperative learning model is the jigsaw technique.^3,5 In this method, students are assigned a topic and placed into two groups: a home group and an expert group. Students in the home group go to the expert group to learn a particular topic and then go to another group to teach that particular subject.³ This technique promotes contributions from each member of the group (positive interdependence and face to face interaction) as well as accountability for each member’s actions (individual and group accountability). Educators that use this model expect their students to support each other’s learning as well as understand that each member of the group must be able to teach a piece of the subject matter to others. In addition, students are expected to communicate effectively with each other using verbal and non-verbal communication (interpersonal and small group talks and group processing).^3,5  This certain isn’t the only example of cooperative learning.  Several other cooperative learning methods exist [See previous blog essay regarding the Processed Oriented Guided Inquiry Learning (POGIL) method].

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In healthcare today, interprofessional healthcare teams are practicing cooperative learning.⁷ In the past, different specialties would work independently and had little appreciation or understanding regarding the unique contribution that other members of the health care team could make.  If students start collaborating in the classroom with their peers, then perhaps this will translate to working with other healthcare professionals.⁷ Health professions educators have an important role in helping students become effective members of a team. In order to implement cooperative learning, educators must promote instructional methods that use the 5 key elements of the cooperative learning model. For example, in the classroom setting, an educator can design case-based group exercises (interpersonal and small group skills and group processing). Students should be encouraged to work in small groups so that everyone has a chance to participate (face-to-face promotive interaction) and learn from each other. During these clinical exercises, the instructor can require that each student to write a reflection on how they contributed to the group’s work as well as evaluate peers (positive interdependence and individual and group accountability). This reflection will allow the educator to see how well collaborative learning is working and student comments can be used to make changes. In practice-based settings, preceptors and other healthcare instructors can encourage interprofessional healthcare teams to use this model of learning when “rounding” in the hospital or during interprofessional meetings in clinic.^4,7 Evaluations of their experiences can be used to individualize students’ needs and provide an overall framework for future collaborative work. The ultimate goal every educator should stress when using cooperative learning strategies in healthcare is to promote optimal patient care.

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Cooperative learning is a model for developing and implementing instructional activities that helps students to develop social learning and leadership skills. ^2,3 Educators and students in the health professions must become proficiency in these skills in order to effectively manage complex patients through team-based collaborations.^4,7

References

1. Salam T, Greenberg H, Pitzel M, Cripps D. Interprofessional education internships in schools: Jump starting change. Journal of Interprofessional Care. 2010; 24(3): 251 – 263.
2. Stavenga de Jong JA, Wierstra RF, Hermanussen J. An exploration of the relationship between academic and experiential learning approaches in vocational education. British Journal of Educational Psychology 2006; 76(1): 155-169.
3. Johnson DW, Johnson RT. An Educational Psychology Success Story: Social Interdependence Theory and Cooperative Learning. Education Educational Res 2009; 38(5): 365 – 379.
4. Budgen C, Gamroth L. An overview of practice education models. Nurse Education Today 2008; 28(1): 273 – 283.
5. Schul JE. Revisiting an Old Friend: The Practice and Promise of Cooperative Learning for the Twenty-First Century. Soc Studies 2011; 102(1): 88 – 93
6. Basak T, Yildez D. Comparison of the effects of cooperative learning and traditional learning methods on the improvement of drug-dose calculation skills of nursing students undergoing internships. Education Educational Res 2014; 73(3): 341 – 350.
7. Mitchell P, Wynia M, Golden R, et al. Core principles and values of effective team based health care. 2012; Discussion Paper, Institute of Medicine, Washington, DC.

The One-Minute Preceptor Technique

by Ahmed Eid, Pharm.D., PGY1 Pharmacy Practice Resident, Frederick Memorial Hospital

As residents muddle their way through postgraduate training, they have countless learning opportunities and witness different approaches to precepting. Residents typically spend far more time grappling with the new information to be learned rather than analyzing the strategy used to teach it. This creates a challenge for them when they transition from learners to preceptors.  Evidence shows that untrained medical educators often utilize inefficient and unimaginative ways of teaching.¹

Participating in a teaching certificate program can help residents develop their precepting skills including the examination of effective techniques to maximize learning. One of the most commonly used teaching strategies in the experiential learning environment is the five-step microskills model of clinical teaching - also known as the one-minute preceptor (OMP) technique. This teaching method focuses not on teaching learners new information, but provoking critical thinking.  The method is intended to promote efficient preceptor-learner interactions. The teaching model consists of five steps: 1) get a commitment, 2) probe for supporting evidence, 3) teach general rules, 4) reinforce what was done right, and 5) correct mistakes.²

The initial step is making a commitment. This step often takes place before the preceptor-learner interaction happens. Through this step the learner assumes the responsibility for making decisions. By forcing a commitment, this helps the learner learn to gather and process information in order to develop a tentative therapeutic plan. It is crucial to create a safe environment where learners can present their thoughts without judgment and to encourage  them to keep the commitment. During this step the preceptor begins to identify areas of weakness and potential teaching opportunities. A common mistake preceptors make during this step is to provide answers to questions learners pose. Instead, the preceptor should ask questions such as “why do you think this is happening?”, “what additional information do you need to make a decision?”, or “how do you prioritize the patient’s problems?” Such questions will not provide answers to learners, but will help them develop their problem-solving skills and keeps the learners engaged.³

Probing for supportive evidence follows.  During the second step the preceptor helps the learner reflect on their decisions and their prior knowledge. This yields an easy transition into the third step — teaching general rules. This is the first time the preceptor starts “teaching” by pointing out knowledge gaps and connections the learner may have missed during the first two steps. The brevity of this model dictates teaching general and succinct information focused on specific facts rather than abstract concepts.

The final two steps of this learning model focus on providing feedback to learners to reinforce appropriate practices and correct mistakes. Positive feedback is not only important for rewarding competency, but also for encouraging the learner to maintain and grow best practices.  Furthermore, reinforcing well-reasoned decisions helps learners develop their self-esteem. It is also appropriate to provide feedback by asking learners to reflect on their performance rather than directly giving feedback, which creates an opportunity to identify areas of improvement in a fashion that is easier for learners to accept and allow the learners to develop their self-evaluation skills.

The model places "correcting mistakes" as the final step because there is a natural tendency for preceptors to point out errors first.  If done excessively, criticisms, even when they are constructive and delivered skillfully, can deter learners from making decisions in the future.  Thus learners begin to avoid making a commitment to a decision in order to evade criticism. To circumvent this negative outcome, some suggest a “sandwich” technique where positive feedback is offered about what was done correctly followed by exploring areas for improvement then closing with a recap of the overall performance with an emphasis on the positive aspects of the performance.

The interaction need not be limited to one minute.  The duration of the encounter should vary based on the needs of the learner and the complexity of the case. In nursing, a five-minute preceptor technique is often used.  The two techniques share similar steps but the five-minute technique fits the needs to students in a nursing environment.⁴ The preceptor should be flexible – a dogmatic adherence to “one” minute isn’t the intent.

The one-minute precepting (OMP) technique was first described in the 1990’s and multiple studies have evaluated its effectiveness in improving teaching behaviors. A randomized controlled trial enrolled 57 second and third-year medical residents.  The study compared the teaching behaviors of residents who received OMP training to those who did not. The study showed statistically significant improvements in almost all teaching skills except “teaching general rules.”⁵ A survey of faculty preceptors found that, after OMP training, they believed learning encounters were more successful and they were better about letting learners reach their own conclusions.⁶ Similarly, a study conducted with nurse preceptors found significant improvements in self-perceived clinical teaching skills.⁷ Finally, after one-minute preceptor training, preceptors performed better in four out of the five microskills compared to preceptors who did not receive the training.⁸  While the evidence supports improvements in teaching behaviors, there is no proof (yet) that learning is improved.  In other words, studies are needed that document improvements in learners’ clinical decision-making skills.

The one-minute preceptor technique is a widely accepted strategy.  It is quick, easy to learn, and engages learners in the critical thinking processes they need to develop in order to be successful in practice.

References:

1. Bazuin CH, Yonke AM. Improvement of teaching skills in a critical setting. J Med Educ. 1978; 53:377-82.
2. Neher JO, Gordon KC, Meyer B, et al. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992; 5: 419-24.
3. The University of Colorado, School of Medicine. Clinical teaching tips- the one-minute preceptor. (Accessed 2016 Apr 9)
4. Bott G, Mohide EA, Lawlor Y, et al. A clinical teaching technique for nurse preceptors: the five minute preceptor. J Prof Nurs. 2011; 27: 35-42.
5. Furney SL, Orsini AN, Orsetti KE, et al. Teaching the one-minute preceptor. A randomized controlled trial. J Gen Intern Med. 2001; 16: 620-4.
6. Salerno SM, O’Malley PG, Pangaro LN, et al. Faculty development seminars based on the one-minute preceptor improve feedback in the ambulatory setting. 2002; 17: 779-87.
7. Kertis, M. The one-minute preceptor: a five-step tool to improve clinical teaching skills. J Nurses Staff Dev. 2007; 23: 238-42.
8. Eckstrom, E, Homen L, Bowen JL, et al. Measuring outcomes of a one-minute preceptor faculty development workshop. J Gen Intern Med. 2006; 21: 410-4.