by Adam K. Saperstein and Francesca Cimino

It takes great skill to facilitate small groups well. Not only do you need to ensure that all members of the group are engaged, but you also have to self-regulate your own responses to allow the group to take the journey, as opposed to being led by you as a guide. While topics that evoke strong personal reactions can cause group members to participate more readily, they can also lead to discussions in which members listen less openly and in which your own reactions blind you as the facilitator to your true role. Such is often the case for the small group sessions in Reflective Practice curricula.

Because small group facilitation is used widely throughout medical education, these tips are not solely applicable to Reflective Practice. There are lots of great links for small group teaching available. Here are a few — these have applicability to the small groups in RP, and often wider applicability for those with other clinical teaching tasks:

1. facultydevelopment_tipsleadingdiscussion
2. https://education.aaaai.org/meded/content/small-group-facilitation-resources

However, over the course of the past few years, I have been fortunate to work with many gifted facilitators who have shared strategies and tips that they find valuable when facilitating. I have compiled these in the below facilitator guide for your perusal and consideration. I am indebted to all who have contributed.

Opening the Session

At the beginning of the session, tell the members of the group how the small group will run. This includes ground rules for engagement and your role as the facilitator. Specific ground rules that most find helpful include:

1. Use “I” statements. Our tendency to use second person statements comes at great cost when participating in Reflective Practice.  Not only is it an example of projecting one’s personal context onto someone else, but it also robs the speaker of the power of their voice.  For example, “You know, when you talk with patients who are in a wheelchair or who have had an amputation, it is very uncomfortable – you just want to talk with them for as short a period of time as possible so you can get out of the room.” Other members of the group may not agree with this at all, but there is an implication that they should. This both prevents the person speaking from recognizing that this perspective comes from their own personal context, and has the risk of causing others in the group to feel less comfortable sharing alternate perspectives. The use of “I” statements is not comfortable for most of us, so emphasizing it is important in order to reinforce this behavior.
   Tip: At the beginning of the session, I emphasize the importance of speaking in the first person. I also let them know that during the discussion, when they speak in the second or third person,  I will lightly tap my own chest to offer them a non-verbal cue to go back into the first person.  
2. Talk to the group. In some environments, there can be a tendency for members of the group to talk to the facilitator and not to other members of the group, even seeking the facilitator’s approval or concurrence.  This can make groups members feel uncomfortable participating if they perceive their comments/perspective will be judged as “right” or “wrong” based on  the degree to which they align with those of the facilitator(s).  Perhaps even more importantly, when an individual speaks only to the facilitator, it can be a sign that they do not appreciate the value and importance of the peer’s contributions – something critical for the delivery of high- quality healthcare.  In a catch phrase – “the power of the group is the group” –  meaning that engagement of all members offers the opportunity to hear diverse perspectives represented and offers a much more rich discussion on which to reflect.
   Tip: At the beginning of the session, I let group members know that I am very good with eye contact. If they find me not looking them in the eye, that is my non-verbal cue for them to talk to the group and not just to me.
3. Emphasize the degree of confidentiality they can expect. This is usually set by the curriculum/course you are teaching, but if not, and if the conversation has any chance at all of addressing personal issues, it is essential to address this at the outset. If no rules exist for the course, but you need them for the group, let the group set the rules. Be explicit about what (if anything) can and what cannot be shared outside the group. In Reflective Practice, the expectation is that (aside from comments about intending to cause self-harm or harm to others) what is said in the group, stays in the group.
   Tip: At the beginning of the session, I ensure that everyone in the group has the same expectation for confidentiality. I do this every session, even if it is the same group with whom I have worked in the past, and even if this is already made explicit by the curriculum/course director. I also share that it is possible that another member of the group will share an insight they feel would be phenomenally valuable for a colleague who is not part of the group.  In those situations, the only scenario in which sharing that information would be OK is if they ask the person who made the comment whether it would be OK to share that specific insight. 
4. Emphasize the value of everyone participating in the small group and that there are no “right” or “wrong” answers. Written reflection allows learners to think about their own reactions and personal context, and to consider how both of these impact the patient care they deliver. Small group discussion affords learners the opportunity to (1) express themselves using another avenue (verbal as opposed to written) and perhaps most significantly, offers learners the opportunity to benefit from the perspectives of others. As such, it is important that each member contribute the discussion – as much for the benefit of others as for any other reason. Important Note: Some students will contribute a small amount to the conversation in a verbal form, but what they do contribute is meaningful and insightful and their non-verbal communication demonstrates engagement in the discussion. Such participation is completely appropriate.
5. Explain your role. In the first few minutes, you are likely to do quite a bit of talking as you set the ground rules. This can demonstrate a pattern of the facilitator talking a lot and the group talking very little. It is essential that you explicitly state that once you finish setting the stage, members of the group will spend most of the time doing the talking.
   Tip:While every situation is unique, I find that the group talking at least 85% of the time and the facilitator talking (at most) 15% of the time is a good general rule of thumb.

Discussion Management/Strategies

1. At the beginning of the session, ask each student what they want to get out of it. Asking this question will help you to identify how you can best help them (individually and as a small community) to reach their goal, and also gives you the opportunity to emphasize the added value that small group discussion offers. Namely, the opportunity to (1) express themselves using another avenue (verbal as opposed to written) and (2) to benefit from the perspectives of others.
2. Prep work:
   
   1. If Learners Submit Reflective Writing Before the Small group: If your learners write a reflective essay in advance of the small group session, take the time to read those reflections. In doing this, look for salient themes that you feel would be valuable to discuss and consider asking individuals to address those themes. Important note: It is critical that you ask this in advance of the session in a private manner (feedback on a paper, personal email, etc.); emphasize that you are only asking them to address this theme if they are comfortable doing so and that it will not have any bearing on their grade if they choose not to; and third, that you do not surprise them in the group by forcing them into addressing the theme.
      
   2. Review the Resources for the Session – for many reflective practice curricula, there are supplemental materials that offer learners stimuli for discussion. Your reviewing these materials both demonstrates your interest to your learners and offers you another way to identify important themes for discussion.
   3. Learn your learner’s names. Learning the names of your learners demonstrates, in a tangible way, your personal interest in them. If not provided, ask for photos of your group – this can be quite helpful. Often, these photos come with a short bio which can be helpful to peruse as well.
   4. Healthy group dialogue. Fostering an environment in which group members feel comfortable engaging is an essential facilitator skill. Below are some common member behaviors that are worth considering.
      1. Conversation Domination. When a member or a small group of members dominate the conversation, others might contribute less than they otherwise would. In addition, those dominating the conversation are robbed of the opportunity to hear others’ perspectives. In many cases, this behavior stems from strong feelings about the topic, but it can also stem from an anxiety about the topic and a desire to not have to confront an internal sense of ambiguity regarding how to handle such a situation. I have found the key to be explaining the value of small group as offering the opportunity to listen to others’ perspectives as the dialogue begins. When this alone does not suffice, here are a few questions that may be helpful to ask:
         – “What do the rest of you think about that?
         – “That’s very interesting – I feel like I have a good understanding for where you are coming from – I’m interested to hear others’ perspectives.”
         – “I sense that you have strong views on this topic and really want to get your point across, which I think you have done very well. I find that when I am in that kind of situation, it really helps me to hear others’ views. What do the rest of you think about that?
         It can be quite helpful to talk to the individual outside of the group, first ask them for their thoughts about the group dynamic and their role in it, and then check in with them to see if they are OK. If so, I follow by affirming their value, offering my appreciation for their contributions, and asking them how they think they grow from the perspectives of others. You may even elect to offer techniques to help them listen first and talk second such as asking them to commit to not being the first person to answer a question.
      2. Disengagement. As noted above, learners who are not talkative are often still very engaged, and offer wonderful insights for the group to contemplate. It is important not to misinterpret a lack of verbosity with disengagement. By contrast, the learner who is disengaged warrants your attention and action. The challenge is to encourage their contributions in a supportive manner. For some, all they need is an opening – they may have had a difficult time engaging in the past or have felt belittled for their contributions – and your invitation opens the door to their engagement. At the same time, I encourage you to trust your intuition – if you sense that something is “off”(obviously easier if you know the learner) you may elect to hold back, and talk with them after the group ends. More often than not, I find that the topic has hit a deep personal chord for them and they are still processing how to discuss it aloud. In most cases, they want to have the dialogue, but need more time. I offer them the opportunity to host a small group on their own with peers, record the conversation and send it to me as their remediation. In every case in which I have done this so far, learners have expressed their appreciation.
      3. Derailing the dialogue. You will likely encounter learners whose comments seem to be tangential at best and unrelated at worst. Before assuming their comments are unrelated to the discussion, pause, see where they are going, and give them the benefit of the doubt. When I am unable to identify the connection to the dialogue, I simply state that aloud. “Jane –I apologize, but I’m having a hard time tracking the connection between [insert the focus of their comment here] and today’s topic. Can you help me understand better?” If the comments repetitively derail the conversation, you may need to be more directive to keep the conversation on track. I also recommend talking with them after the session one on one.
      4. Insensitivity. In most situations, insensitive comments are not malicious, but that does not necessarily make them any less painful. There are times when you will feel the need to step in, but I encourage you to give the group the space to address the insensitivity – in most cases, others will challenge the insensitive comment, and peers redirecting the offender can be far more helpful in affecting long term behaviors and establishing social norms than the facilitator stepping in. If this does not happen, call out both the individual to explain their comment and the group, emphasizing the responsibilities we each have as a member of our community.  Tip: If you perceive that member(s) of the group are being frankly rude (demonstrated by making fun of answers and people, cutting others off, or other actions that offend members within the group), step in. Remind everyone of the group guidelines again, and definitely have the one-on-one conversation outside of group to let the person know how important a safe group is, and what they can do to help make that happen.

Closing the session

1. Summarize what the group has discovered.. As the facilitator, helping the group to see where they have come during the course of their discussion can be very helpful. This frames the experience and help group members make and cement connections between concepts discussed. Thereafter asking them how they might approach similar challenges in the future, and writing those down, can be very valuable for each member of the group.
2. Offer your own narrative. Sharing personal experiences related to the topic in question, describing the challenges you faced and how you dealt with them can help learners make connections between concepts discussed and real life scenarios. This is particularly valuable when your learners are relatively inexperienced in the area being discussed. Offering this towards the end of the session is important – doing so early in the dialogue can lead learners to believe that your approach is the only “correct” approach and can also intimidate them from sharing (and processing through) their reactions and thoughts.
3. Reiterate confidentiality This reinforces group expectations and supports the safety of the learning environment.
4. Leave them with your contact information. If you are comfortable doing this, you will find that many of your learners reach out to ask follow-on questions after the session. In some cases this will be months or years later. I have found these discussions to be as valuable for me as my learners describe them as being for them.

 

AKS 2/10/15; edited 7/10/18