A Student-led Process to Enhance the Learning and ...

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Original Research Paper

A Student-led Process to Enhance the Learning and Teaching of Teamwork Skills in Medicine Chinthaka Balasooriya1, Asela Olupeliyawa2, Maha Iqbal3, Claire Lawley4, Amanda Cohn5, David Ma6, Queenie Luu7 Senior Lecturer and Director, Medical Education Development, School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, 2Sessional Academic, Medicine Education and Student Office, UNSW Medicine, 3Scenario-group Facilitator, School of Public Health and Community Medicine, UNSW Medicine, 4Medical Officer, Royal North Shore Hospital, Sydney, Australia, 5Medical Student, UNSW Medicine, 6Medical Officer, Prince of Wales Hospital, Sydney, Australia, 7Medical Officer, Royal Prince Alfred Hospital, Sydney, Australia

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ABSTRACT Context: The development of teamwork skills is a critical aspect of modern medical education. This paper reports on a project that aimed to identify student perceptions of teamwork-focused learning activities and generate student recommendations for the development of effective educational strategies. Methods: The project utilized a unique method, which drew on the skills of student research assistants (RAs) to explore the views of their peers. Using structured interview guides, the RAs interviewed their colleagues to clarify their perceptions of the effectiveness of current methods of teamwork teaching and to explore ideas for more effective methods. The RAs shared their deidentified findings with each other, identified preliminary themes, and developed a number of recommendations which were finalized through consultation with faculty. Results: The key themes that emerged focused on the need to clarify the relevance of teamwork skills to clinical practice, reward individual contributions to group process, facilitate feedback and reflection on teamwork skills, and systematically utilize clinical experiences to support experiential learning of teamwork. Based on these findings, a number of recommendations for stage appropriate teamwork learning and assessment activities were developed. Key among these were recommendations to set up a peer-mentoring system for students, suggestions for more authentic teamwork assessment methods, and strategies to utilize the clinical learning environment in developing teamwork skills. Discussion: The student-led research process enabled identification of issues that may not have been otherwise revealed by students, facilitated a better understanding of teamwork teaching and developed ownership of the curriculum among students. The project enabled the development of recommendations for designing learning, teaching, and assessment methods that were likely to be more effective from a student perspective. Keywords: Collaborative learning, medical education, student perceptions, teamwork, teaching and learning methods

Context This paper reports on a project that utilized the skills of student research assistants (RAs) to explore their peers’ views and inform the development of teamwork learning and teaching activities in the undergraduate medicine program at the University of New South Wales (UNSW) in Australia. Teamwork Access this article online Quick Response Code: Website: www.educationforhealth.net

DOI: 10.4103/1357-6283.120698

has been identified as important for effective clinical practice, and targeted teamwork training and workplace quality improvements in acute and chronic care settings have resulted in better clinical outcomes and fewer medical errors.[1,2] This project was initiated in response to the widely held perception that teamwork is often taken for granted and undervalued by medical students in spite of its importance. The project aimed to explore student perceptions of teamwork learning and teaching approaches and recommend activities that would better engage students. Literature Review Graduating doctors require competence in teamwork in order to provide effective patient care. However, studies have found that junior doctors are ill prepared for multidisciplinary

Address for correspondence: Dr. Chinthaka Balasooriya, Director, Medical Education Development, School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, Sydney, NSW 2052, Australia. E-mail: [email protected] 78

Education for Health • Volume 26 • Issue 2 (August 2013)

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Balasooriya, et al.: Enhancing the Learning and Teaching of Teamwork Skills

teamwork and managing relationships with senior doctors.[3] Through a previously published review of the literature and studies with clinical supervisors of junior doctors, we found that the critical competencies in teamwork for medical graduates are ability to communicate well with the team, awareness of one’s own role and responsibilities, and skills to promote supportive team relationships such as understanding team roles, respect and assertiveness. [4,5] Many medical education programs have sought to integrate teamwork skills into their curricula. We provide a brief outline of the recent literature on teaching teamwork to medical students within university curricula, and in particular the literature on students’ attitudes towards these teaching efforts. A variety of methods have been employed in medical and health professions curricula to develop students’ teamwork skills. These include classroom-based peer learning, interprofessional education (IPE) and simulation-based learning. These methods have had varying degrees of impact. A systematic review found that curriculum interventions that are IPE-based and simulation-based are modestly effective, particularly in enhancing medical students’ understanding of team roles and improving their team skills to some extent.[6] This review further suggested that engaging participants in active learning and using reference teamwork models may promote teamwork development.[6] Several systematic reviews of IPE identified that the authenticity of interprofessional learning experiences, where learners see the direct relevance to current or future practice, is associated with the development of teamwork knowledge and skills.[7,8] A review of peer teaching in medical education found that peer teaching promoted leadership skills, skills of soliciting and giving feedback, and skills in the future role as an educator.[9] An evaluation of Team-Based Learning (TBL) in multiple medical schools found that student engagement and communication skills improved in addition to academic performance.[10] However, IPE initiatives may not positively influence students’ attitudes towards other healthcare team members,[8] while medical students have had mixed opinions on whether TBL aid their development of leadership skills and respect for others’ opinions.[11] A number of factors have been found to influence student perceptions of the value of teamwork and the educational impact of teamwork teaching. These include students’ gender, maturity, type of health profession, degree of professional socialization, and learning orientation.[12-15] Another relevant question is how students’ attitudes change at various stages of their training. Students surveyed after one year of TBL noted that their peers now contribute equally in teams, but their perceptions of development of teamwork skills became more negative with time.[11] Some longitudinal surveys of IPE initiatives have found that student perceptions of their Education for Health • Volume 26 • Issue 2 (August 2013)

teamwork skills improve but they become more critical of IPE as they progressed in the curriculum and subsequently entered professional practice,[16,17] but others have found that attitudes towards IPE do not significantly change over time or with exposure to IPE curricula.[14,18] Studies also suggest that varying student attitudes strongly influence student engagement with teamwork teaching. Positive attitudes towards working in teams and early and repeated exposure to TBL were associated with subsequent greater use of TBL, while a perceived lack of efficiency of TBL teaching methods and resistance to peer evaluation was associated with limited use of TBL.[10] Students who had negative attitudes towards IPE from the outset gained least from courses and activities utilizing this educational strategy.[16] The literature discussed above highlights the variability of student perceptions and attitudes towards teamwork teaching and the possible educational consequences. These varying perceptions need to be considered in making curricular decisions on teamwork teaching. For instance, although advocates of team training and IPE purport that optimal teamwork training should be commenced early in medical education,[19,20] evidence conflicts on the ideal timing. It is not known whether IPE is more appropriate to commence early (at the beginning of a health professional’s training) before prejudices develop or later when individuals are more confident of their teamwork skills.[16,17] There is also debate on the efficacy of teamwork training in those who are unwilling to engage in it from the outset.[13,14,16] The literature also suggests that some areas of the curriculum lend themselves better to teaching in team-based formats.[10] While there seems to be general agreement that teamwork training should be an essential component of medical education, further work is needed to understand how best to engage students with teamwork content throughout the duration of their educational program. Study Aims This project aimed to explore how medical students at various stages of their training perceive teamwork-related educational activities. The project solicited students’ opinions on how best to design educational activities, with the goal of using this information to help guide the development of more effective learning and teaching strategies.

Methods Study Setting The study was set within the medicine program at the UNSW, which places a high degree of emphasis on the development of professional attributes that include ethical practice, effective 79



communication, and teamwork. The UNSW Medicine program utilizes a range of stage-appropriate strategies to iteratively support students’ development of teamwork skills as they progress through the course. Initially in the first and second years of the program, students engage in structured activities that include team-based group projects and assignments, small group learning sessions, role play, debates, and assessment tasks that require them to learn about healthcare teams. In addition, a formal online peer-feedback system provides additional evidence of students’ achievements in this capability. As the students progress through the curriculum, teamwork skills are developed through direct participation in clinical teams in the hospital setting. A portfolio-based assessment system based on graduate capabilities that include teamwork provides a framework within which students’ development in teamwork can be tracked across the entire program from entry to graduation. Study Design The project employed medical student RAs to explore their peers’ perceptions. Student RAs in years 3, 4, 5, and 6 of the Medicine program were recruited through an open advertisement. Forty-five (45) students expressed interest and shortlisted candidates were invited to a selection process. The selection activities provided an authentic basis for selection of students who were best suited for the project tasks. They consisted of a brief introduction to the activities expected to be undertaken, practice of mini-interviews within the group, and reporting back of practice interview findings to a selection panel of faculty. A total of 14 student RAs were recruited and were given further training on how to conduct peer interviews. An online module was set up to coordinate the project activities and provide students with support in interviewing skills and ethical aspects of research. Ethics approval was received from the Human Research Ethics Committee of the university. Student RAs were provided with an interview guide to be used to elicit their peers’ views on the usefulness of specific activities in developing teamwork skills, the skills that they felt were adequately developed or required further development, the ideas or activities they felt might improve teamwork skills teaching, and perceived barriers to developing teamwork skills. Participants were recruited by a general email invitation to students’ university email addresses, inviting them to contact one of the student RAs if they wished to participate. Student RAs worked in pairs to interview students and each pair interviewed between 8 and 10 students. A total of 52 students were interviewed. One student RA asked the guiding questions and engaged with the interviewee, while the other recorded the responses on a standardized form. The student RAs subsequently used a template to record a de-identified summary of each interview, and these summaries were shared within 80

the RA group on the secure online discussion board to prompt further discussion. In preparation for the next stage, student RAs analyzed the summaries and identified the key themes in the data. One member of the research team independently analyzed the reports and in consultation with the research team reviewed and ratified the themes. The RA group was engaged in a structured brainstorming session conducted by an experienced facilitator external to the research team. This session led to discussion of the themes and development of preliminary recommendations. These recommendations were based on the interview findings, but were shaped through discussion among student RAs who had experience across the program (years 3-6), and were thus able to take a broader view of feasibility and effectiveness. The recommendations were further developed at a second brainstorm session that was facilitated by a member of the research team, which led to the development of specific recommendations for each stage of the medicine program. These recommendations were further reviewed and refined by members of the project team and wider faculty, in consultation with members of the RA group. The themes that emerged and the recommendations that were developed are discussed below.

Results Theme 1: Highlighting the Relevance of Teamwork Skills to Clinical Practice Junior students highlighted the need to emphasize the link between teamwork skills learnt in early stages of the medicine program and the skills required in clinical settings. Students suggested that learning activities be “more clinically based, for example, [focused on] case studies on how the multidisciplinary team deals with clinical scenarios. Perhaps [include] role plays where each person is a [different] member of the team, and they would each have to research what role they play in the team.” Students in later years of training consistently suggested that theoretical exercises in teamwork were not useful and indicated that they would benefit more from practical experience: “Make it more clinically relevant! Possibly even dedicate clinical time to discussion on teamwork; for example, ask tutors to tell us about how they work in teams.” However, deeper discussion of such experiential learning opportunities revealed that students often missed the point of the activities, suggesting that they needed a theoretical framework to benefit from these. The theme that emerges from these statements is that teaching of theoretical aspects needs to be explicitly linked to potential practical applications. Recommendation Student RAs suggested developing a learning activity based on a mock multi-disciplinary team (MDT) meeting, with a role being assigned to each student. It was suggested that these Education for Health • Volume 26 • Issue 2 (August 2013)



activities be offered iteratively as students progress through their medicine program, with similar but more advanced activities to be arranged in more senior years. In order to maximize the benefits of these sessions, it was suggested that pre-session activities would be required to develop students’ awareness of relevant criteria that highlight the relevant teamwork skills and competencies.

Recommendation The curriculum development group should design an instrument to iteratively assess group interactional skills during small group learning sessions and to assist in providing structured feedback to students. This will also provide the basis for a more objective assessment of teamwork skills by small group facilitators.

Theme 2: Enabling Junior Students to Appreciate the Significance of Teamwork Skills

This recommendation also supports the development of some key areas of need identified by students broadly related to managing the dynamics of their team. Students identified the need to develop skills in leadership, organization, critical evaluation, delegation, and providing feedback. Managing conflict and managing “difficult team members” in particular were areas in which they needed further support.

Senior students also reflected on how as junior students, they were unable to appreciate the relevance of certain teamwork-based activities. They suggested that junior students would benefit greatly from discussion with senior medical students through a formalized system of peer mentoring. Recommendation A peer-mentoring system, supported by the faculty, should be established with an appropriate method to select mentors most suited for the role. Theme 3: Recognizing and Rewarding Teamwork Students highlighted the view that university learning tends to be individual focused and that it is sometimes not conducive to collaboration. They indicated that even group activities were often divided up by students into smaller, individual tasks, thus minimizing the need for collaboration. There were mixed views on the usefulness of small-group learning sessions in fostering teamwork skills. Students suggested that the success of these sessions was largely dependent on the quality of facilitation. Students also expressed the view that within the current assessment system, it was more important to complete the “group” task even if that (paradoxically) meant working as individuals rather than collaboratively, and this was (unintentionally) reinforced by the grading system. Students reflected that unequal contributions by team members and consequent high workload for some individuals often led to negative perceptions of group-based activities in general. The current assessment system was therefore viewed as a disincentive to engagement with teamwork, and students suggested that awarding marks for team contributions would encourage more engagement. Students noted the need to emphasize the importance of teamwork within small group learning sessions by assessing teamwork within these settings and providing feedback to students: “Facilitators need to do more to ensure everyone participates- perhaps give participation mark that counts towards portfolio.” Education for Health • Volume 26 • Issue 2 (August 2013)

Theme 4: Self and Peer Assessment Students expressed mixed views about the usefulness of the present online peer-feedback system that enables students to provide anonymous feedback to their colleagues upon completion of each group project. Some students felt that this helped them develop skills in providing constructive feedback to peers. In contrast, other students suggested that the system was not useful because some students tended to use the system to provide generic positive feedback to everyone. Students recognized the importance of developing skills in critically evaluating their own teamwork (using criteria provided) in collaborative settings such as project group meetings and clinical group meetings. Recommendation The curriculum development group should design an individual teamwork assessment task for which students would be expected to gather evidence of relevant interactions (e.g., recordings of meetings), and reflect on the teamwork skills that were used or should have been used. Theme 5: Better Utilizing the Clinical Environment to Develop Teamwork Skills Students described the variability of experiences that they had during clinical attachments as “highly dependent on your team and partner in the rotation.” Students highlighted the need for a more “standardized student experience” and for a more structured role as a team member in the clinical team. Students were concerned about the variable experiences that they had during ward rounds and requested faculty to develop a more systematic way for students to be truly included within the clinical teams to which they are attached. Examples of such strategies included the allocation of specific roles or responsibilities so that students could make a real contribution to the team, rather than feel like “outsiders.” 81



Students reiterated that the perceived exclusion from the “functioning” clinical team limited their opportunities to develop collaborative skills. They suggested that the focus on the clinical application of teamwork skills should be maintained through activities such as “Shadowing doctors or nurses in hospital and write a report on how they interact with others in various teams throughout the day.” Recommendation The faculty should introduce a mechanism to support the development of relevant teamwork skills during routine clinical experiences. It is recommended that teamwork sessions be arranged during the preinternship period, based on real or simulated clinical situations, with allocated roles and peer observers who will provide feedback based on clear criteria. The above mechanism could be supported by an instrument for direct observation of behaviors that would enable students to focus on relevant teamwork skills, receive feedback, reflect, and further develop relevant skills.

While the method was strong in enabling a deeper and clearer understanding of student perceptions, it is important to acknowledge the limitations of such a process. The recruitment of participants was dependent on students volunteering to be interviewed and could have been influenced by the natural dynamics that occur between students – this could introduce some bias to the findings. It is also necessary to recognize that the student perspective has limitations by its very nature, as students do not necessarily have a comprehensive view of the requirements of a teaching program. This limitation was recognized and addressed at multiple stages of the project, where the student perspective was considered alongside faculty input, through informal and formal discussions. The two brainstorm sessions (the first externally facilitated and the second internally facilitated) were also used to address this limitation. Further research using a range of methods to elicit the views and perceptions of faculty members, health professions educators, and graduates of this program would enable a more comprehensive understanding of this issue.

Theme 6: Developing Skills to Better Engage with Other Health Professionals

Discussion

Students requested more exposure to common problems that may arise in interdisciplinary interactions, as well as learning opportunities around specific skills that are needed when coordinating support from different professionals.

The student-led process helped ensure that the recommendations of this project truly represented students’ views, and the iterative nature of the process helped ensure that the recommendations were carefully considered and feasible. This method had the unique advantage of drawing out student perceptions that may not otherwise have been revealed. For example, the recommendation of novel learning strategies such as peer mentoring networks did not emerge in exploration of similar curricular areas carried out earlier through a standard interviewer-led process. RA reports highlighted that participants were more comfortable expressing honest opinions and described how some participants expressed their views only after reconfirming confidentiality of the interviews. RAs also described how the common “student experience” between RAs and participants enabled participants to discuss views based on examples that were familiar to both groups. Previous studies have found that involving students in obtaining feedback on curricular matters from their peers results in free expression of student views.[21] Studies have also suggested that involving students as researchers adds rigor to processes of obtaining student feedback, encourages faculty to be more responsive to student recommendations, and in turn prompts both students and faculty to take shared responsibility for the recommendations thereby transforming student and faculty thinking and consequent curriculum change.[22] The active participation of the RAs in exploring their peers’ perceptions and in developing recommendations for learning activities suggests that a transformative process in student thinking may have taken place during our project. This is an area that deserves further exploration. The students provided an array of suggestions

Recommendation The curriculum development group should design structured group-based assessment tasks based on mock MDTs. This would provide students with an opportunity to explore and analyze how various disciplines collaborate in routine patient care. Students should be encouraged to reflect on their experiences across clinical teams and analyze similarities and differences in group process. Even though there was a strong emphasis on clinical activities to promote teamwork skills, there were some suggestions for more general and extracurricular activities to promote teamwork “Co-curricular activities with allied health students.” These views related to developing the interpersonal aspects of interprofessional interactions, where informal interactions between students of various health professions may be helpful. Some students also expressed the view that teamwork skills are generic skills that most students possess before entering the university and therefore do not need to be formally taught within the formal curriculum. This is an important perception to engage with, when implementing teamwork focused learning activities. Limitations This project utilized a novel method to gather student perspectives on the learning and teaching of teamwork. 82




for educational interventions in developing teamwork skills, and it would be interesting to understand how educators would respond to the student perceptions. Similarly, it would be critical to explore how educators could respond to diverse ways in which students perceive educational interventions. Previous studies have suggested that varying perceptions have the potential to influence the impact of even the best designed educational interventions.[13,23-25] This project enabled us to identify a range of student perceptions that can influence the effectiveness of teamwork-focused learning and teaching activities. One main theme that emerged was the need to make the link between collaborative learning and healthcare teamwork clearer through teaching and learning strategies such as role playing, simulations, and peer mentoring by more senior students. Previous research has found that in teaching teamwork skills to first year medical students, clearly stating the clinical relevance of the learning activities motivates the students.[26] Our findings suggest that students value vertical integration of teamwork content as appropriate to their stage of learning, and they increasingly appreciate the relevance of teamwork as they progress through the curriculum.

influence the effectiveness of teamwork learning and teaching activities. These recommendations provide the basis for an integrated approach to the development of teamwork skills within health professions education programs.

Acknowledgments The work of this project was supported by Associate Professor Anthony O’Sullivan, Associate Professor Chris Hughes, Dr. Rachel Thompson, Dr. Elizabeth Tancred, Ms Edna Koritschoner, Dr. Silas Taylor, Prof. Philip Jones, and Dr. Peter Harris, who formed the original project team and supported project activities. The enthusiastic efforts of the entire student RA group and student participants are sincerely acknowledged.

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Within peer group learning and assessment strategies, students perceived that reward for individual participation in group processes would foster teamwork skills development. They also believed that the existing self-evaluation and peer-feedback systems on group process should be more structured and more timely. Research has identified five critical elements of effective collaborative learning through extensive work in secondary and higher education: Positive interdependence (individual contributions to the group effort) and individual accountability, face-to-face interaction, small group skills, and engagement in group dynamics.[27] Our findings suggest that summative and formative assessment methods should aim to promote these elements, particularly positive interdependence and individual accountability. Several areas for improvement within clinical education were identified. These include more active participation with the healthcare team and in particular with other health professionals, guidance by clinical tutors, and structured processes for reflection on healthcare team-based activities. A model for clinical learning suggests that “supported participation” is a critical element of such learning,[28] while a systematic review suggests that reflective practice is a critical but often neglected element in clinical education.[29] The findings of our study clarify how these can be achieved in relation to developing teamwork skills. The multi-stage process by which the findings were analyzed and synthesized enabled the development of specific recommendations to address a range of issues that could Education for Health • Volume 26 • Issue 2 (August 2013)

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How to cite this article: Balasooriya C, Olupeliyawa A, Iqbal M, Lawley C, Cohn A, Ma D, et al. A student-led process to enhance the learning and teaching of teamwork skills in medicine. Educ Health 2013;26:78-84. Source of Support: This project was funded by an internal University of New South Wales ‘Strategic Learning and Teaching Development Fund’ grant, administered through the School of Public Health and Community Medicine, UNSW Medicine. Conflict of Interest: The authors are teachers, students and graduates of the UNSW Medicine program. The authors have declared no conflict of interest.
