TUTORS TRAINING WORKSHOP REPORT (1989)
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TUTORS TRAINING WORKSHOP REPORT (1989)
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UNIVERSITY OF NEW MEXICO
U.S.A .
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TUTOR TRAINING WORKSHOP
November,
1989
GOALS OF THE PRIMARY CARE CURRICULUM
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The Primary Care Curriculum provides an opportunity for students to obtain a
medical education experience which emphasizes the skills necessary for lifelong
learning. The science basic to medicine is learned in the context of medical
problems through the use of the scientific method (clinical reasoning process).
The goals of the Primary Care Curriculum include a wide range of activities.
1.
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SCIENTIFIC REASONING
The student will be able to approach clinical problems with
appropriate scientific reasoning (identifying and prioritizing problems,
generating and testing broad hypotheses), integrating information from
the basic and clinical science disciplines. The student will be able to
function effectively in an environment of ambiguity and uncertainty.
Assessment:
Individual Process
preceptorship, ward performance
2.
Assessment,
tutorial
group,
SCIENTIFIC CONTENT
The student will attain a v/orking knowledge of the basic and clinical
sciences and be able to describe pertinent abnormal physical or
behavioral process(es) and their interrelationships in all the patient’s
identified problems. The student should be able to describe these
events in appropriate pathophysiological, psychological or sociological
terms, listing the facts that support the process(es) identified. If the
student feels that several possibilities exist on the basis of the data
available, they should be listed in order of importance (likelihood,
urgency, etc.).
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Assessment:
Individual Process
preceptorship, ward performance
3.
Assessment,
tutorial
group,
RESEARCH ASSESSMENT SKILLS
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When studying a medically-related report (journal, monograph, paper,
presentation, abstract, poster, etc.), the student will be able to critically
assess the questions being posed and their significance; the
appropriateness and limitations of the methods being used; the
consistencies and significance of the data and data differences; whether
the conclusions are consistent with the data; the remaining unanswered
questions; and the relevance of the information to current problems.
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Assessment:
4.
Tutorial group
RESOURCE UTILIZATION
When faced with medical problems requiring further expertise for
proper diagnosis or management, the student will be able to identify
and efficiently utilize an appropriate quantity and quality of resources
including texts, journal articles, library and community resources and
faculty.
Assessment: Individual Process Assessment, tutorial group, preceptor
ship, ward performance
5.
LIFELONG LEARNING
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Students will continue to demonstrate a high level of motivation in the
pursuit of the sciences basic to medicine. They will demonstrate the
ability to utilize the clinical experience with patients as a stimulus for
self-directed study.
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Assessment:
6.
Tutorial group, preceptorship, ward performance
COLLECTION AND PRESENTATION OF DATA
The student will be able to collect adequate data from the patient
using the appropriate range of interview and examination skills. The
student should then be able to organize the information into a concise,
problem-oriented written document and succinctly present the problem
and its analysis orally.
Assessment: Individual Process Assessment, preceptorship and ward
performance.
7.
INTERPERSONAL SKILLS
The student will demonstrate interpersonal skills and cultural awareness
necessary' to facilitate patient communication, patient understanding of
problem(s) and proposed management, and patient comfort. The
student should be able to demonstrate insightful and constructive self
end peer-criticism. The student should be able to build a team
relationship with other students and health professionals, appropriately
identifying and utilizing their input in problem assessment and
management; and help other students and health professionals learn to
accept and provide constructive criticism with other students and health
professionals.
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Assessment:
Individual Process
preceptorship, ward performance
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8.
Assessment,
tutorial
group,
COMMUNITY AND FAMILY HEALTH
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The student will be able to demonstrate an :ability
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to describe the
impact of the health problem on the patient, the patient’s family and
the community.
The student will be able to identify family
relationships and factors in the community and environment which
might have positively or negatively influenced the identified health
problems.
The student will be able to assess the interaction between the patient
and the community in terms of health prevention and maintenance.
Assessment:
Tutorial group, preceptorship and ward performance
9.
COST CONTAINMENT
The student will be able to indicate the cost of proposed treatment
and management and demonstrate an understanding of the mechanisms
whereby patients are able to pay for health care services.
Assessment:
Tutorial group, preceptorship and ward performance
In the Primary Care Curriculum, all skill areas are introduced concurrently and
are gradually developed and evaluated from the beginning of medical school.
Thus, skills build in complexity as students gain facility in integrating them in the
context in which they are used. This is a vital component of problem-based
medical education. Further, the student will be exposed to a breadth of career
opportunities and practice settings, from urban tertiary care to rural primary care,
to permit the student to make more realistic decisions about future residency
selections and practice options.
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GROUP PHASE DEVELOPMENT
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orientation
i Interaction during the orientation phase is aimed at trying to decide whether
■ to be in the group or not. Some questions which members need answered include:
Do I fit in? Do I want to be in this group? Am I going to be ignored? What
i behaviors are allowed in this group? During this phase two "types emerge who
may begin to engage in conflict: dependent (rely upon a strong leader) and
independent (reject leadership) members.
| The tutor’s role during this phase may include: making sure the rules and
regulations are clear (whether generated by the group or the tutor), and not
; abdicating the position of leader/facilitator/tutor . A supportive climate
: needs to be built from the beginning.
' CONFLICT
' By the end of the first phase group members may feel "swallowed up ” by the
; group, given all the polite orientation which took place. Individuality gets
! asserted, and this is best accomplished through conflict, Conflict usually
centers on at least two areas: how
1— close and personal members should be; and
—
| who/what should the leader/leadership be. Power is the issue. The first area
of conflict is promoted by the overpersonals (who desire unconditional love)
and the underpersonals (who reject any affection in the group). The second
area of conflict is promoted by those who believe the leader/tutor is god (or
God or maybe even GOD), and those who believe he/she is a fool (or Fool, or
maybe even FOOL). Moderates, those who belong to neither group, hold the group
together and eventually work out a peace.
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The tutor’s role during this phase is, first of all, to stay out of the fighting
avoid taking sides (it is easy to reinforce the "leader is god", group and overlook the concerns of the other subgroup). The aim is to reduce hostility by
keeping lines of communication open, by promoting discussion of the sore areas,
and by establishing (continuing to establish) a supportive, confirming climate.
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balance/high work
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is balanced; leader-as-god versus
Personal identity versus a group identity
:
.
versus
far
is balanced; task versus social
leader-as-fool is balanced; close
The
balance
may
be
tipped
at any moment, but until
(appears) is balanced. -a
tremendous amount of good
the group is in high gear, producing
it 1happens
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work.
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less central than during the other
The tutor’s; task during this phase is no
■ ■ to sit back and allow
phases. A
A usual problem at this point is for the tutor
The
tutor
needs to stay alert
on
his/her
face.
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—self-satisfied grin to appear
(cont)
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; to the balance and move to recover it should it be disrupted. Also, during
; this phase the group will have a tendency to ignore the socio-emotional needs
i of the members. The tutor needs to introduce discussion to care for these
; needs, e.g. ”rap sessions” unrelated to the specific task of the tutorial.
i PARTING/DISINTEGRATION
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Disintegration of educational groups is rather obvious since a time limit is
i usually imposed on the length of interaction. The first sign of disintegration
: is talk which is highly affectionate. The second sign is talk about control
factors in the group, e.g., who did what and how well. And the third sign is
talk related to inclusion in the group, e.g., statements of goodbye, talk about
other groups to come, and work to be accopmlished after the group. Two subgroups
■- often emerge during this phase (without necessarily conflicting with each other) :
I those who uninvest/divest themselves of the group by making disparaging remarks,
and those who react to their feeling about the group ending by denying that the
f group need to disband at all.
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The tutor’s role during this phase is to, first, understand his/her own feelings
about the group ending and, second, empathize but avoid taking sides with either
; subgroup.
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Taken from:
Small Group Communications
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Lawrence Rosenfeld, Ph.D.
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Dept, of Speech Communications - UNM
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GUIDE TO QUALITY TUTORIALS
s Evaluation of Knowledge: Depth and Dreadth
Deals with specific details without losing the big
picture (overview).
Example:
Promotes understanding of learning issues on at least two
levels of knowledge, e.g. tissue and cell; normal and
pathological; adult and child, etc.
Example:
Asks for complete explanation of.basic mechanisms.
Example:
Requires use of the blackboard to illustrate and diagram
concepts and relationships.
Example:
Models critical appraisal of data.
Example: Tutor describes or requires description of
methods and limits of data cited from student (journal
articles, statistics).
Requires correlation of learning issues with patient's
problem.
Example: Discussion of mechanism of plaque formation in
atherosclerosis related to shortness of breath in
coronary care.
Probes understanding of rate limiting/key steps in basic
science mechanisms-
Example:
Challenges students to think about what has been learned
by using the ’’What if..." paradigm (changing data and
situations).
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Example:
Asks for clarification of concepts, terms, diagrams.
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Example:
Knowledge: Depth and Breadth (continued)
Requires focused and specific learning issues
Example:
Is sensitive to psychosocial issues in cases, patients
and tutorials.
Example:
Tutorial Evaluation
Models honest, constructive feedback to individuals and
group at the end of each tutorial.
Example:
Models self evaluation„
Example:
Uses learning prescriptions to facilitate setting of
unit goals and to evaluate knowledge, skills, attitudes
and behaviors.
Example:
Conducts mid and end-unit evaluations efficiently and
thoroughly«.
Example:
Helps students recognize their own biases and values.
Example:
Guides students to plan what they can do better next
time.
Example: Too many learning issues; students study
differently or present without notes.
Leaves adequate time for evaluation at the end of
tutorials.
Example:
Deals with problems when they occur.
Example:
Tutorial Evaluation (continued)
Models criticism of behaviors rather than personalities.
Example: "I don't like it when you interrupt me. .
versus ’’You're too aggressive.”
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Helps group to use specific examples when providing
constructive feedback.
Example:
Factors cultural differences into evaluation and
feedback.
Example:
Presentation Skills
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Provides feedback on presentation of information.
Example:
Stresses organization, clarity and precision of
presentations.
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Example: Complete but overwhelming patient presentation.
Challenges students to listen and evaluate peer's
presentations critically.
Example:
Sets high standards.
Demonstrates and models teaching and presentation
methods.
Example:
Corrects pronunciation and specific use of technical
language.
Example:
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Evaluation of Teaching Skills:
Asks open, probing questions, not the ’’guess what I'm
thinking” type.
Example: Name two kinds of
were, ...
if the liver
Maintains continuity and focus of discussion by asking
for periodic summaries.
Example:
Reflects questions back to th
Example:
Establishes a positiv
Example:
Treats students with respect.
Example:
Helps to ide
with faculty, visits to clinics, etc.
Example:
Serves as a resource person
Example:
Evaluation of Group Process:
Promotes active listening.
Example:
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Insists that one person speaks at a time.
Example:
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Helps each
facilitator.
Example:
Intolerant
of uneducat
’’apple
bobbing.”
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Group Process (continued):
Helps to establish clear ground rules for group at
beginning of unit.
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Example:
Facilitates renegotiation of ground rules when necessary.
Example:
Creates open environment for discussion.
Example:
Facilitates resolution of interpersonal conflicts.
Example:
Helps group to "own” their tutorial and assume
responsibility for their collective and individual
learning.
Example:
Promotes efficient use of time.
Example:
Keeps group on track.
Example:
Is flexible and supportive of group.
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Example:
Recognizes own limitations.
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Example: Says
tt
I don't know” and models this behavior.
Actively involves learners in group process.
Example:
Uses n j „ messages.
Example:
Is aware of and uses body language to communicate.
commun,ty he
Example:
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Group Process (continued):
Helps group resolve conflicts using •'win-win” methods.
Example: Works with group to find shared goal.
Makes his/her expectations clear to group.
Example:
Clarifies students' expectations of group and of tutor.
Example:
Helps group to establish and stick to an agenda.
Example:
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STUDENT EVALUATION OF THE TUTOR
STUDENT
74 School of Medicine
pmary Care Curriculum
TUTOR
jd-Unit
6d-Unit
DATE
This evaluation of tutors is used by the program to determine
jtor strengths and weaknesses, and is used as tutor training and
lhancement. In addition, a composite evaluation is sent to the
tor's department chairman and entered into the faculty file.
Please bring this completed form to mid- and end-unit
aluations. Comment on each category using specific examples
enever possible^
KNOWLEDGE BASE - CONTENT LEARNING
Probes understanding of material to full extent. Challenges
application to other situations. Requires students to relate
learning issues to patient's problem.
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PROBLEM BASED LEARNING PROCESS
Encourages problem identification and hypothesis generation.
Facilitates reranking of hypotheses for purposes of closure.
Encourages multi-system approach to patient problems (e.g.
VINDICATE). Helps students identify focused learning issues.
STUDENT CENTERED LEARNING
Respects students as peer group learners. Active participant in
group discussions. Maintains a non-authoritarian role. Each
student is given the opportunity to lead a case discussion.
Encourages student-to-student interactions.
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Models honest feedback. Models
critical listening. Encourages effective Pres®n^f°n.
.
material by each student. Helps group to "own their tutorial
and assume responsibility for their collective and individual
learning.
^Xs^Solve group conflict.
stJSE OF UNIT RESOURCES
! sessions with
Helps to> identify and arrange specific resource
u.s, etc.
as a
facultyt visits to clinics,
etc. Serves
Serves as
a resource person
seek
outside
experts
when appropriate,
and encourages group to i--exhibits
and
materials.
Familiar with cases and case
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STUDENT EVALUATIONS
to facilitate setting of unit goals
Uses learning prescriptions to
skills,
and
behavior.
and to evaluate knowledge, o'----, attitudes
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Models honest, constructive feedback to mdividu .
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the end of each tutorial.
Regularly informs students of
progress/problems. Facilitates follow-up <and
re-evaluati .
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^COMMENDATIONS
In which area of tutoring does this tutor demonstrate
exceptional abilities?
__11 this tutor modify in order to
What one area or attribute could
more effectively facilitate the
-- tutorial process?
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THE FUNCTIONS OF TUTORIAL GROUPS
I The fundamental goal of the tutorial is to enable each student to develop a system of
| problem-based learning in order to acquire and utilize the science basic to medicine
| and other attributes necessary to become an effective physician and to sustain lifelong
I learning.
OUTLINE
S I.
Use problem-based learning in the group to:
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identify appropriate learning issues and resources for information;
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C.
summarize, discuss and integrate back into the problem information obtained
from individual learning.
A.
transmission of information;
B.
interpersonal interactions.
A.
learning of basic and clinical science information;
B.
use of reasoning process;
C.
identification of appropriate informational resources;
D.
use of communication and evaluation skills.
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Use the group to develop effective communication skills with respect to:
III. In the group, assess the performance of the group, peers and self with regard to:
■ IV.
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actively discuss and develop an approach to case problem(s) using the
reasoning process;
A.
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Use the group for support for:
A.
emotional needs;
B.
social interactions;
C.
personal growth.
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THE FUNCTIONS OF TUTORIAL GROUPS
i Introduction
As is stated on the cover page of this document, the primary goal of the tutorial is
to help each student to develop a system of problem-based learning so that he or she
i can learn the science basic to medicine as well as other areas of knowledge which will
make it possible to be an effective physician who will continue to learn throughout
his/her career.
j It should be stressed that although PCC utilizes tutorial groups, the learning, as in any
other program, is essentially an individual process and each person is responsible for
acquisition of knowledge. In the words of a previous tutor, ''Groups don t learn,
individuals learn". The tutorial, then, is the place where learning issues are developed
^ncTinformation is shared, discussed and integrated back into the medical problem.
■ Further, it is a place where clarification of concepts can occur as well as a place to
It share useful resources.
. As you can see from the outline on the previous page, there are three primary
‘ the tutorial
‘ group. First, you will be learning how to use and
activities which occur in
t apply the reasoning process for the solution of medical problems. Second, you will be
I improving
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•'on
■.in irrvti-r
’-Kr to communicate
nir*ntp witb
ability
with otHe.rR
others, both
both in
in regard
regard to
to medical
medical
your oKiii
Third,
you
will
be
learning
self
and
peer■ information and interpersonal skills.
j assessment skills.
| Your group must establish its own modus operandi and establish what rules it will
I follow.
follow. How your group operates is up to you. However, keep in mind what the
1 purpose of the tutorial is and frequently evaluate whether your particular tutorial group
| is making adequate progress toward that purpose.
Throughout the rest of this document we discuss a number of behavioral objectives for
| the tutorial that we haveestablished and give you some suggestions as to how you
j might effectively proceed. For
Forexample,
example, probably
probably one of the first issues you will
| encounter will be how often your group should meet,
meet. Your decision will depend on
■ how
how the
the group
group feels
feels and how
how much
much time
time isis available.
available. In the past, groups have
” three
’
•times
’
at spaced intervals for
| generally met at least twice and usually
a week,
’
| sessions of 2-5 hours. Remember: Each individual is responsible for his/her own
| learning, and for making sure the tutorial meets his/her needs.
| What follows surveys the functions of the tutorial and offers some useful suggestions.
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USE PROBLEM-BASED LEARNING IN THE GROUP
j are expected to utilize, at least at the outset, the PCC model of
You and; your group
| the reasoning process to facilitate your problem-based learning. Your group may want
I to modify this process subsequently as long as you can show that any such changes
| make your learning more efficient and effective.
With each case, the group is strongly encouraged to keep a record of its progression
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’• through the reasoning/learning process (see
document
on Reasoning
Process),
effective means for recording the reasoning process is to use large newsprint sheets
C / of the transcribed
and felt-tip markers.. You should take turns as recorder. Copies
information could be made available to rest of the group, so as; to serve as a record
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for later reference when you come in contact with similar cases, for general review/, and
for preparation for the "Individual Process Assessment" (IPA), which is given for
evaluation at the end of each unit. For certain cases during the unit, you will be
expected to first develop the case independently and then bring this work-up to the
group for comparison and evaluation with those of other members. This exercise will
function to assess the reasoning process of each member of the group and to identify
individual strengths and weaknesses. This should also be an additional help for
preparation for the IPA.
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Actively Discuss and Develop an Approach to Case Problem(s),
At the initiation of a case, your group will actively discuss and develop an
approach to it. Initially, it may be more effective to open up the group to ’’brain
storming”, with each member, in turn, freely suggesting initial ideas. This should
be limited to a relatively short period of time, e.g., 15 minutes, after which the
group can then pursue those ideas deemed most fruitful to further develop the
case and identify learning issues. You will develop the case as far as you can,
drawing upon the collective knowledge of the group in terms of data gathering,
informational knowledge, and hypothesis generation.
B.
Identify Appropriate Learning Issues and Resources for Information.
The discussion should enable the group to identify key learning issues. In some
cases, it may be more effective for each member of the group to study the same
issues. At other times, it may be more effective for individual group members
to study different learning issues with the aim of integrating those areas of study
back into the case at the next meeting. It is important that all members
communicate to the group the types of resources that were particularly helpful to
them. It should be emphasized that with each case, each of you should seek to
primarily study areas which you have not dealt with previously or those areas of
which you do not yet have an adequate understanding.
Yet you should
periodically attempt to re-apply to the current case information learned in the
past.
C.
Summarize, Discuss and Integrate Back Into the Problem Information Obtained
From Individual Learning.
With the newly-acquired information, the group can now pursue the case further
either to its final resolution or to another point where additional study is needed.
The group will serve as a very effective reference point by which you can assess
the depth and breadth of information you are obtaining in comparison to other
members.
II.
USE THE GROUP TO DEVELOP EFFECTIVE COMMUNICATION SKILLS
It is important to everyone to communicate effectively to make the tutorial successful.
This entails communication of information as well as feelings at the personal level.
We are all developing professionals, and we come together with varying abilities to
communicate; it is only through active practice that we can improve upon this ability,
It is important that each member become an ;active participant in the group in order
his/her unique knowledge and ideas to the learning process.
to contribute
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Transmission of Information
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You will have the opportunity to present information to the group in a variety
of ways. Each of you will be expected to periodically present and summarize
information about the patient from the case, just as you will have to do as a
practicing physician. You will also have the opportunity to summarize information
and concepts to the group either from what you already know or from what you
have learned. It should be emphasized that these are not envisioned as "mini
lectures" or "show and tell times", but rather they should be delivered as succinct
personal communication tailored to meet the needs of the group. A clear or
unique description of a concept can be particularly helpful to the group since this
is frequently more difficult to learn than are facts. At times, this communication
may be better done outside of the group if only 1 or 2 members are interested,
or if time is inadequate during the group meeting. Group time also offers an
excellent opportunity to share references and resources which are particularly clear
and helpful.
Another important area of communication is to formulate appropriate questions
relevant to the case. The only question which can be considered "stupid” is the
one that is not asked. In our experience, questioning is one of the most
important means of facilitating learning, not only for the individual asking the
question but for the group as a whole. It can serve to keep the group focused
and from getting "bogged down". It also can help other group members by
forcing them to clarify more precisely information and concepts which they are
presenting.
An area which is sometimes overlooked is clarification of terms being used in
regard to definition and pronunciation. It is estimated that during his/her medical
training, a student must learn 10-20,000 new terms. It is of vital importance that
each of you acquire and practice this ’’language of medicine”. If you are unsure
of a term being used, you should seek clarification from the group.
a B.
Interpersonal Interactions
It is essential that the tutorial becomes more than a cold, pragmatic assessment
of medical cases and information. We all communicate more effectively when we
can open up with our true feelings and share "who we are".
Effectively
communicating feelings and personal concerns to a group in a manner which
provides for constructive resolution does require a degree of skill not necessarily
developed by all of us. Any group of people who work together closely and
consistently over time is going to experience issues of conflict, time management,
varying leadership styles, listening abilities, and abilities to give constructive
criticism and feedback. These are all skills that can be taught, but are best
learned in the context of experience, i.e., at the time when the group is
confronted with the problem involving any of these issues. The responsibility for
improving group communications lies not only with the tutor but with every
member of the group.
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I III. USE THE GROUP TO ASSESS THE PERFORMANCE OF THE GROUP,
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PEERS AND SELF,
We need to be able to assess ourselves, our peers, and the group as a whole in four
!■ areas: learning of basic and clinical science information, use of reasoning process,
j. identification of appropriate informational resources, and use of communication and
evaluation skills.
This is one of the most important and difficult areas which must be dealt with in the
tutorial. It is next to impossible to grow as professionals or individuals without honest
and open assessment of our behavior. Others are usually reluctant to give us open
criticism unless we actively encourage it and honestly desire to receive it. Further,
unless we really want to be evaluated by others, their comments will often be ignored
or misperceived. Criticism should not be constmed by the recipient as a personal
attack. To lessen the likelihood of that occurring, your comments should be given in
a context of caring and honesty and, most importantly, should address specific items
which the receiver can change or modify. Further, we should make sure that we
address those aspects of the person being evaluated that he/she asked to have assessed.
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IV. USE THE GROUP FOR SUPPORT: (A) EMOTIONAL NEEDS, (B) SOCIAL
INTERACTION, AND (C) PERSONAL GROWTH.
The tutorial is a small group of people with common interests and concerns and similar
goals. It provides a unique opportunity for individuals to provide and receive support
in several areas common to personal well-being.
Opportunities often arise for
individuals within the group or the group as a whole to administer to emotional needs.
It also provides opportunity for social interaction and the development of friendships.
Finally, through its openness and caring, the group can enhance each individual’s
growth.
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PROBLEM-BASED LEARNING
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INTRODUCTION
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Problem-based learning is a process whereby students learn by utilizing a problem as a
stimulus to discover what information they need to learn in order to understand and
move toward the solution of a problem. In the case of the Primary Care Curriculum,
the instruments used in the learning process are biopsychosocial problems of selected
patients. These will be presented to you in a variety of formats.
I It is most important that the student develop a rational system of inquiry in order to
I effectively identify what he/she needs to learn in order to understand the underlying
| mechanism of the problem and, in addition, to proceed with obtaining the most likely
solutions. This reasoning process has been called the ’’Clinical Reasoning Process".
If you examine the elements of the reasoning process, however, you readily recognize
that the process is really a general mechanism for providing a rational approach to
any problem, but in our situation, the language is that of medicine.
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I
|
|
I
Before defining the reasoning process, one general statement is probably in order. It
is recognized that different people will eventually shift or add to the elements of the
process according to their background, their perception of the world and their
perception of rationality. These differences are perfectly acceptable. One must only
be sure that the final process is, in fact, reasonable. With these forewarnings in mind,
it is intended to present a model of the reasoning process. It is presented only
because it is one which has received a lot of attention and has been found to be
used, in its essential elements and sequence, by a number of recognized excellent
physicians (See Barrows and Tamblyn, Problem-Based Learning: an approach—to
medical education. Springer Co., New York, 1980).
I. The Reasoning Process
A.
Identify Problem(s).
Identifying problems involves answering the question: "What is wrong
with the patient?" As a rule, most patients will state at least one major
problem when they tell the physician why they have come to see him/her.
A patient may have more than one problem. It is the job of the
physician to discover these problems through inquiry, examination and
other evaluative procedures.
The identification of problems is a
continuous procedure.
B.
Generate Hypotheses of Causes and Mechanisms by Which„JCause2
Creates Problem(s).
Consider an individual who comes to your office with chest pain, i.e., the
problem. To generate ideas about causes, one must ask the question:
’’What kinds of conditions can lead to chest pain?" One approach might
N
P
0
c
s
s
be to relate the "problem” to the various organ systems.
list might include:
1)
2)
3)
4)
A beginning
A muscle in the chest is damaged (neuro-muscular);
Something is wrong with the patient’s heart (cardiovascular);
Since stomach problems often result in pain in the chest,
something could be wrong with the patient’s stomach
(gastrointestinal);
Something has happened to the patient’s lungs (respiratory).
In a like manner, hypotheses about mechanism might include the
following:
1)
2)
3)
4)
Muscle damage could be caused by being hit by a ball or
straining during lifting;
Pain originating from the heart could result from an
infectious process in the fluid surrounding the heart;
The stomach could cause pain by being the site of an ulcer
or a cancer; it can occasionally penetrate through a defect
in the diaphragm and thereby be eroded;
An infectious process within the lungs could cause pain or
a rubbing of the lining of the lungs (pleura) against the
chest wall, which can also cause discomfort.
You will note that the hypotheses about mechanisms are somewhat more
specific than hypotheses about causes. As you investigate further, you will
note that the increase in specificity of hypotheses is the usual course of
the process.
As you look at the list, it is certain that you have thought of additional
causes and mechanisms. This is an important point: The physician
should continuously re-examine the list of hypotheses concerning causes,
adding to it and eliminating depending on other new information.
C.
Rank Hypotheses
As you generate your list of hypotheses, you will automatically start to
think that certain causes and mechanisms are more likely to be correct.
This process is called ranking of hypotheses. Once you have ranked your
hypotheses, you will want to further investigate what is actually wrong.
One usually starts by going down the list, raising certain hypotheses
higher on the list, lowering some, and possibly adding new ones
depending upon what further information is obtained.
D.
Test Hypotheses Using Present Data and Information and New Data
and/or Information.
The way in which one goes about testing an hypotheses involves
accumulating information which is either consistent or inconsistent with
' . Care must be taken to seek and give equal weight to
a given view.
consistent and inconsistent information.
1.
History and Physical Data
One can gather data while examining and talk with the patient.
For example, in the illustration in the proceeding section, one
might suspect some kind of recent physical event if the cause of
the chest pain were muscle damage. Careful questioning about
accidents or undue physical exertion may help to assess this
hypothesis.
2.
Laboratory Data
Another source of data is through the use of laboratory and other
diagnostic tests such as x-rays. Using the example of chest pain
again, if one suspected damage to the heart, it might be detected
on x-ray or on analysis of blood for certain constituents released
from damaged tissues.
3.
Information from Resources
Following are a few sources of data/information gathering; these
are meant to be illustrative rather than all inclusive.
E.
(a)
One can obtain information from the library.
Such
information could come from determining which causes are
most frequently associated with chest pain.
One could
determine if different causes of pam are associated with
different qualities of pain. Reading can also be useful in
indicating what steps one can take next in order to further
test the hypotheses.
It will help you m answering the
question, "What do I need to know to understand what is
happening?” One event which must occur when using the
library (or for that matter any other resource) is to
continuously evaluate and validate the information you are
obtaining. Does it really relate to the problem you are
considering? Are the data which have been presented in
the articles sound and valid? Are the conclusions consistent
with the data?
(b)
You can get information from your colleagues and from
experts in different fields. Having gathered the data, you
now have to decide what to do with it.
Rerank Hypotheses
Sometime during the data gathering process you will want to step back
and ask yourself what have you found out and what it means. In order
to do this, one has to first summarize in some way all of the data
obtained. Having put it into some kind of useable form, the next step
is to ask how the data help differentiate any one of the several
hypotheses you have generated.
You may also want to add new
hypotheses at this point. You may also want to rerank your hypotheses.
There is no set rule as to how often one should summarize and analyze
data. It will depend on your own style, the nature and severity of the
patient problem itself, as well as the nature of the new data you obtain.
At this point, you may have decided that you need additional data; you
can go back to collecting it from the appropriate sources and repeat the
steps in the process.
During the process of summarizing and analyzing the data you will be
putting the data into certain patterns which will indicate that one or
more of the hypotheses are unlikely and that one or more are likely.
When you have a reasonably adequate amount of information, it may
then be possible to redefine your hypotheses in terms of specific clinical
entities. These "working” hypotheses will relate to what is wrong with
the patient, and you will generalize the data into as complete a picture
of what is wrong as possible. In medical terminology, this is called
reaching a diagnosis or diagnoses. At this point you may also want to
ask new questions and decide how you are going to answer them.
F.
Treat to Manage Problems.
This involves development of a treatment plan, and at early stages in
your education you may not proceed very far in this step. However, you
may at least proceed by asking the question, ’’What do 1 do for the
patient now that I think I know what is wrong?” The steps should be
put into a rational model similar to the one presented above.
II.
PROBLEM BASED LEARNING
A.
.)
Identification of Learning Issues
During the course of developing hypotheses and gathering data, you have
probably asked questions for which you did not have ready answers.
Using the chest pain example once again, you may have wondered how
stomach difficulties result in chest pain. When such a question is asked,
you have identified a "learning issue", i.e., an issue about which you
would like to have further knowledge. During the complete course of
analysis of a patient’s problem(s), a large number of such learning issues
will appear. There will be many occasions when the number of such
learning issues will appear. There will be many occasions when the
number of issues will be greater than can feasibly be investigated in the
time available to you. In such instances, you will have to make decisions
as to which issues will be pursued. Such decisions may be made in
collaboration with other members of your tutorial group. Other issues
which you may want to pursue should not be neglected, but pursuit of
those issues may have to be done outside the time devoted to
preparation for a tutorial.
B.
Evaluation of the Process and Knowledge Obtained
There are two aspects with whichi one should be concerned in evaluation:
the reasoning process itself, and evaluating what was learned.
(1)
The reasoning process itself
Did the steps you took lead to a reasonable decision about the
' o Did
make you identify
difficulties of the patient?
j ’ the problem
'•
learning issues and stimulate your desire to learn? Was what you
learned of value to you in analyzing the patient problem, or was
it extraneous to the critical issues?
(2)
Evaluating what was learned
Some possible questions are: What new areas of medical science
Did you reach an adequate depth of
have you explored?
understanding of the issues? How efficiently were you able to
What or who were the best
get the required information?
What
did
you
learn
about
mechanisms of disorders?
resources?
Has the information you’ve learned met your learning needs?
Additional questions can be asked, and some of these questions are
applicable to the reasoning process as well as to the learning process.
C.
Transference of Knowledge Obtained to New Situations
One definition of knowledge is that it is the functional utilization of times
learned to applicable situations. In order to apply new information you
must develop a system of data retention (memory) and of recall. There
are probably as many ways of doing the latter as there are people.
Some suggestions are file systems, organized notes, organized reference
books, commitment to memory or even use of a computer. The ultimate
aim is to generalize information so that it can be retained and used in
the future in dealing with other clinical problems.
OUTLINE OF THE REASONING PROCESS
I.
IDENTIFY PROBLEM(S)
II.
GENERATE HYPOTHESES of:
A.
Causes and
B.
Mechanisms by which ’’cause" creates problems(s)
III. RANK HYPOTHESES
IV.
N
I
V.
I___
TEST HYPOTHESES using:
A.
Current data and knowledge
B.
New data and/or knowledge
I
RERANK HYPOTHESES
(Most likely hypothesis is tentative diagnosis)
VI .
I
TREAT to:
Manage problem(s)
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EVALUATION GUIDELINES IN "PASS/FAJLLSXSTEM
The general philosphy of the Assessment Committee and the Evaluation Review
Committee in PCC is that most students will do well most of the time. All students
will have areas that they need to improve, and occasionally students will not perform
in a satisfactory manner. The majority of students’ time is spent preparing for/or
functioning within the tutorial, and tutorial evaluation represents the major source of
feedback for the student in the first two years of PCC.
The normal evaluation steps include written and verbal, mid-unit and end-unit
evaluation by student and tutor. The student’s grade for a particular unit will remain
incomplete until all four documents have been turned in and reviewed by the
| Evaluation Review Committee. It is expected that the verbal mid-unit and end-unit
evaluation will provide feedback to the student in all the areas covered by the
evaluation form.
|
I
1j
I■
i
Historically, PCC has attempted various ways to foster cooperativeness and to decrease
competitiveness. Students and faculty alike recognize that students are competitive, but
towards
i.it is_ hoped that the
- - new evaluation scheme will foster healthy
. - competition
. improving
one
’
s
skills
and
knowledge
base,
rather
than
trying
to
impress
faculty
and
i x
others so as to improve a GPA.
i
!
|
j
|
It is important when filling out evaluation forms (tutorial1 or IPA) to describe
behaviors rather than characteristics. Behaviors can be altered and, in general,
characteristics cannot be. Being a ’’nice guy" is a positive attribute, but is not
interested,, -cooperative
and compassionate way towards
modifiable. Behaving in an ----------—E
others is a behavior that can be encouraged.
j Students and faculty alike recognize that there is always more to learn, skills to
improve and style to modify, so evaluations that mention only the positive are
incomplete and not helpful. Very specific suggestions for improvement or descriptions
of inappropriate behavior may result in change. General and only positive comments
! will not allow directed change on the part of the student.
j The Evaluation Review Committee reserves the right to return to faculty and students
; evaluation forms which have been inadequately completed. The Committee will also
1 at times request in-person discussion, particularly when there are major discrepancies
| in descriptors between students’ and tutors’ forms.
Bert Umland, MD
8/89
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STUDENT AND TUTOR SATISFACTION IN_THE_CXASSR.OOM
If seems reasonable to look at the classroom - the interaction within as well as the
1 products which result from that interaction - as an organization, and to apply research
' on job satisfaction done in more usual organizational settings to the educational setting.
1 The conclusions below are supported by available research on job satisfaction in nonj educational (classroom) settings.
e
s
1.
Satisfaction depends on whether an individual’s own goals are met.
2.
Successful outcomes, e.g, accomplishing the task, determine level of satisfaction.
c
c
3
The amount of perceived influence an individual has determines his/her level of
satisfaction.
>4
' 4.
The amount of perceived influence an individual has with work-related matters
determines his/her level of satisfaction.
7
E
K
' 5.
Having had past experience with similar work content and/or process-determines
an individual’s level of satisfaction.
i
6.
■
Satisfaction is also dependent upon several variables related to a supportive
communication climate:
a.
the degree to which co-workers are found attractive (task attraction, physical
attraction, and social attraction are all involved);
b.
the degree to which the group is cohesive;
c.
the degree to which members of the group trust each other;
d.
the degree to which conflict is constructive;
e.
the degree to which group members find it easy to communicate with each
other;
f.
the degree to which group members feel "in" on things happening in the
group;
g-
the degree to which group members get sympathetic help with job-related
and non-job-related problems; and
h.
the degree to which group members feel appreciated for their work.
From:
Small Group Communication (425)
Lawrence Rosenfeld, PhD
Dept, of Speech Communications - UNM
A
u
CHARACTERISTICS OF A FUNCTIONAL TUTOR
1.
Questions and probes the reasoning process and critical thinking - elicits students’
reasoning process, poses questions, challenges information, critiques
2.
Facilitates and supports good interpersonal relationships in the group - open,
honest, willing to facilitate critical feedback
3.
Active member of the group - enthusiastic, friendly, interested in participating,
has time for the group, contributes
4.
Willing to serve as a resource person - limits "bog downs” in group discussion
by clarifying issues or information
5.
Guides/directs/intervenes - keeps group on track and/or on task
6.
Promotes application/integration/synthesis of information to the patient case or
other interdisciplinary issues
7.
Promotes the use of resources - brings in or suggests appropriate resources,
encourages use of a variety of resources
8.
Flexibility - comfort with or willingness to "explore" areas outside area of
expertise
Copyright
1986 by Susan Lucero,
Joan Christy and Primary Care Curriculum.
All rights reserved.
PRACTICAL SUGGESTIONS FOR TUTORS
TO FACILITATE STEPS OF THE
REASONING PROCESS AND PROBLEM SOLVING
A
: SUMMARY
1.
Tutor encourages analysis, synthesis, and evaluation of data.
2.
Tutor encourages students to model his/her behavior in asking for reasons,
justifications, etc.
3.
Tutor intervenes appropriately to keep discussion on
information, and to stimulate thinking.
track,
to give
SUGGESTIONS
1.
Tutor elicits student’s reasoning process.
If student asks for more
information from the presenter, e.g., "Did patient vomit?", tutor might ask
"What are you hoping to find out? What are your reasons for asking that
question? How would knowing the answer make a difference in your
approach to the patient’s problem?"
2.
Tutor encourages hypothesizing, asks for the reasons why_sp.ecifm_hypotheses
are suggested, and elicits evaluation of hypotheses. Tutor might ask, "What
do you think is going on with this patient? What reasons do you have for
offering that specific hypothesis? What evidence would rule in or out these
hypotheses?" One student suggested that tutor should ask, "What disease,
or other processes could have caused this?", rather than asking, "What
caused this?" The student thought that the former approach would elicit
many hypotheses to work through and evaluate.
3.
Tutor maintains continuity and focus of discussion, by asking for periodic
summary, for evaluation about what has taken place, and ..where discussion
is going. Tutor might ask, "Will someone summarize what has taken place
thus far?
Who would want to summarize that presentation in thirty
seconds? What would we look for now with this patient?"
4.
Tutor encourages students to make connections. Tutor might ask, "What
is the association between hypertension and headaches?
How might
interdisciplinary issues about patient life-style be related to this case?"
5.
Tutor emphasizes open-ended questions to promote discussion rather than
izing quiz-type
questions which
focusing on yes/no type questions or emphas
< _
,
are not integrated with discussion.
6.
Tutor emphasizes mechanisms and causes of patientsL-probiems. Tutor
might ask, "What processes could have caused this problem? What are the
mechanisms involved here?"
7.
Tutor periodically asks students to explain and define, medical terminology
used. Tutor might ask, "What is cholesterol? What does that level of
cholesterol usually mean?"
8.
Tutor does not simply answer all questions that are asked, bht appropriately
deflects them back to the group. Tutor might ask, ’’Does anybody know the
answer? How might we go about answering that question? What impact
will the answer to your question have in regard to approaching the patient’s
problem?”
9.
Tutor encourages students to refine their presentations and make them more
precise. Tutor might ask, "How might you quickly summarize what you
have been saying? What’s a more precise way of saying that? How could
you better organize that to get your point across more effectively?"
From Tutor Notebook, University of Illinois School of Clinical Medicine at UrbanaChampaign.
a
WHAT TO LOOK FOR IN GROUPS
!
An Observational Guide to Group Process
In all interactions between people, there are two major ingredients: content and
process. The content is the subject matter or the task on which the group is working.
■ In most situations, the focus of attention of all persons is on the content of what is
being discussed. The second ingredient is the process by which the discussion is taking
‘
‘ beingProcess
is a term used to refer to how
place, or the_ task that
is
pursued.
working
together;
it^is*
concerned
with what is happening between and to
people are 1
group members while the group is working on its task.
To study group process, or group dynamics, means to learn about communication,
influence, decision-making, styles of leadership, struggles for control, competition for
prominence, morale, conflict, cooperation, feelings about the task and how the group
is working, and whether people are listening to one another and responding to> one
another, etc. To be concerned about group process is to be concerned about the
extent to which a group is utilizing its resources most effectively.
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- -- ----------
-----------------
------------
-
,
In most situations, little attention is paid to process, because the task consumes most
of our energies and interest; this often remains the case, even when a group’s
ineffective process is the major cause of the difficulties it is having with its task.
Awareness of group process and sensitivity to its importance enable us to identify group
problems effectively. Since every group has a process, and sometimes has some
difficulties with its process, awareness of this important area enhances a person’s value
to a group and is likely to make him or her a more resourceful participant in the
group’s work.
Below are some observational guidelines to help observe and talk about group process.
A.
Participation
One indication of involvement is verbal participation. Look for differences in the
amount of participation among members.
1-4.;
■'
1.
Who are the high participators?
2.
Who are the low participators?
3.
Do you see any shift in participation, e.g., highs become quiet; lows
suddenly become talkative. Do you see any possible reason for this in the
group’s interaction?
4.
How are the silent people treated? How is their silence interpreted?
Consent? Disagreement? Disinterest? Fear? Boredom?
5.
Who talks to whom? Do some people respond almost exclusively to certain
others in the group? Do you see any reason for this?
6.
Who keeps the ball rolling?
7.
Look for instances of nonverbal participation. Do some people frequently
communicate non-verbally? What kinds of things do they say?
B.
Influence
Influence and participation are not the same.. Some people may speak very little,
yet they capture the attention of the entire group. Others may talk a lot, but
people pay little attention to them.
C.
8.
Which members are high in influence, i.e., when they talk, others seem to
listen?
9.
Which members are low in influence, i.e., others do not listen to them or
follow them; is there any shifting of influence?
10.
Do you see any rivalry in the group? Is there a struggle for leadership.
What effect does it have on other group members?
Decision-making Procedures
Many kinds of decisions are made in groups without considering the effects of
these decisions on other members. Some try to impose their own decisions on
the group, while others want all members to participate in the decisions that are
made.
D.
11.
Does anyone make a decision and carry it out without checking with other
group members (self-authorized decision)? For example, a student decides
on the topic to be discussed and starts right in talking about it. What
effect does this seem to have on other group members?
12.
Does the group drift from topic to topic? Whose suggested topic receives
the best response?
13.
Who supports other members’ suggestions or decisions?° Does this support
result in the two members deciding the topic or activity for the group
How does this appear to effect other group
(handclasp decision)?
members?
14.
Is there any evidence of a majority pushing a decision through over other
members’ objections? Do they simply run over any minority?
15.
Is there an attempt to get all members participating in a decision (consensus
testing)? What effect does this seem to have on the group?
16.
Do people make contributions which do not receive any kind of response
or recognition? What effect does this seem to have on the person?
Task Functions
These functions illustrate behaviors that are concerned with getting the job done,
or accomplishing the task of the group.
17.
Does anyone ask for or make suggestions as to the best way to proceed
or deal with a problem?
18.
Does anyone attempt to summarize what has been covered or what has
’
•
Mf’
been going on in the group?
E.
19.
■ j or asking for facts, ideas, opinions, feelings, feedback,
Is there any giving
for alternatives?
or searching
f
20.
Who keeps the group on
tangents?
target, prevents "topic jumping" or going off on
Maintenance Functions
These functions are important tor maintaining relationships between members of
the group They are necessary to create effective working relationships among the
members.
F.
21.
Do members show an interest in one another?
22.
Are members asked for their opinions?
respected and encouraged?
23.
What is done to maintain a free and orderly discussion?
24.
How are differences resolved?
25.
Does the. group pay attention to members’ feelings as it proceeds with the
there
work? Are
.
----- tensions that are not dealt with?
Are differences of opinion
How are conflicts handled?
Feelings
During any group discussion, feelings are frequently generated by the interactions
b"Sn members. These feelings, however, are sometimes not alkedl abom.
Observers may have to make guesses based on tone of voice, facial expressions,
gestures, and other forms of nonverbal cues.
26.
What signs of feelings do you observe in group members: anger irritation,
frustration, warmth, affection, excitement, boredom, defensiveness,
competitiveness, etc?
27.
G.
Do you see any attempts by group members to block the expression of
feelings, particularly negative feelings? How is this done? Does anyone
do this consistently?
Norms
Standards or ground rules always develop in a group in order to control the
behavior of members. Norms usually express the beliefs or desires of the majority
of the group members as to what behaviors should or should not take place i
the croup They are do’s and don’ts. These norms may be clear to all members
(explicit?’known or sensed by only a few (implicit), or they may operate
completely outside the awareness of the group members. Some norms help group
progress and some hinder it.
28.
I
Are certain areas avoided in the group (e.g., discussing how people feel
about what others are doing, openly confronting conflict, talking abou the
leader’s behavior, etc.)? Who seems to reinforce this avoidance. How do
they do it?
29.
Are group members overly nice or polite to each other? Are only positive
feelings expressed? Do people avoid disagreement and seem to agree with
each other too readily? What happens when people disagree?
30.
Do you see norms operating about participation or the kinds of questions
that are allowed (e.g., Tf I talk you must talk. If I share my reactions,
you too must share your reactions.”)? Do people feel tree to probe each
other about their feelings?
Do questions tend to be restricted to
intellectual topics or events outside the group?
All of the above factors are included within the concept of group process.. This is a
new term for most of us. When we talk about how we are working together, this is
a discussion of process. It
1 is often useful for vgroups to learn to encourage members
to share their ideas and feelings about how the group is working, and to do so at the
same time the group is working on its task. In addition, groups frequently choose to
schedule the last few minutes on their agenda for a process discussion, i.e., how did
we work today, and what can we learn from this meeting that will help us work
together more effectively in subsequent meetings?
The reason for learning to talk about process is, or course, to facilitate work on the
task.
I
CRITERIA FOR FEEDBACK
Feedback is a way of helping another person to consider changing his behavior.
Feedback is communication to a person which gives him information about how
effective his work or actions appear to be. Feedback helps an individual to keep his
behavior "on target"; thus, it helps a person to better achieve his/her goals.
Some criteria for useful feedback are described below:
1.
Feedback is descriptive rather than judgmental. Describingj one’s own reaction to
another person’s work leaves the other person free to use the
L feedback or not use
Avoiding
judgmental
language
reduces
the other’s need to
it, as he/she sees fit. /
~J \
respond defensively.
2.
_______
‘ . A balanced description of a person’s
Feedback is both positive
and negative
behavior or actions takes both the strong and weak points into account, Both
give the other information for change.
3.
Feedback is specific rather than general. To make a general statement about
another person’s work as a whole does not tell a person which parts of his/her
performance or actions need changing and which might serve as models.
4.
Feedback takes into account the needs of both the receiver and the giver of the
feedback. What you say to a person about his/her performance not only reflects
his/her work or actions, but also how you think or feel about them at the
moment.
5.
Feedback is directed at behavior which the receiver can do something about.
When a person is reminded of some shortcoming over which he/she has no
control, the major change is in terms of an increased frustration level.
6.
Feedback is solicited rather than imposed, Feedback is most useful when the
receiver himself has formulated the kind of question he/she most wants an answer
to.
7.
‘ n,. What the giver intends to
Feedback is checked to insure clear communicatio
with the im,pact it has on the other person. Asking
say is
isnot always synonymous
y
about the meaning of doubtful feedback can clear up the discrepancy.
8.
Feedback is directed primarily at a person’s performance or behavior rather than
at the person him/herself.
9.
Feedback is most useful when given immediately after work has been completed
or behavior has been exhibited.
From:
J
Cooperative Learning Project, University of the District of Columbia
aassKi
FACTORS THAT AFFECT THE COURSE OF CONFLICT
Interpersonal
relations
Perception
Attitudes toward
one another
I
Task orientation
Cooperative
Competitive
Open lines of communi
cation
that
furnish
relevant information to
members.
Cooperation is more
practical than competi
tive.
Each party is concerned
with informing and being
informed.
Open and honest com
munication is better than
no communication.
Lack of communication.
Misleading
communi
cation.
Spying, infiltrating to
gain upper hand.
Information receiving is
more important than
information giving.
Parties look for similarities and common
interests.
Each shares common
fate, mutually dependent
for
maximum
gains,
minimum losses.
Individuals willing to
minimize
differences
brought to situation.
Recognize
and
exaggerate
differences
(values, goals, concerns).
Produces stronger bias
toward
genuinely
misperceiving
others
neutral or conciliatory
actions as antagonistic.
Encourage
trusting,
friendly attitude.
Characterized by accurate,
well-informed
positive
cognitions,,
feelings.
Willingness to act supportively in response to
needs or requests arising
from conflict.
Breeds hostility, negative
attitudes.
desire
to
Facilitates
exploit needs of others
and respond negatively
to requests.
Willingness to define
terms of conflict.
Each party must collab
orate in pursuit of
solutions.
legitimacyRecognizes
rights of others interests.
All parties utilize power,
influence, talents jointly.
Any resolution must be
biased toward one side
or other.
No mutual
gain. Strategies involve
enhancing one’s own and
diminishing others power.
Others concerns are not
as important as own.
Tends to expand agenda
past problem to other
issues.
All-out testing,
not one issue.
Summary: 1)
Each style encourages behaviors leading to more of the same
behaviors.
2)
Wisdom: knowing what behaviors are indicated so that correctives
may be applied expediently.
3)
Competitive processes hinder conflict resolution; cooperative processes
facilitate conflict resolution.
Adapted from:
M. Deutsch, "Conflict and Its Resolution," in C. Smith (ed.), Conflict
Resolution Contributions of the Behavioral Sciences (Notre Dame,
Ind.: University of Notre Dame Press) 1971.
MANAGING INTERPERSONAL CONFLICT
To resolve interpersonal conflicts, you need to find effective ways of communicating
during a conflict, and of course, you want to create an outcome satisfying for everyone
concerned. There are primarily three styles of resolving conflicts, each has its
advantages and disadvantages.
Win-Lose:
Win-lose conflicts are ones in which one person gets what he oi she wants while
the other comes up short. The most common conflict strategies used in win-lose
conflict are power, dominance, and forcing. Of course, 'power may be presented
in physical threats, use of authority, or even intellectual or mental ways (such as
driving your opponent crazy through the use of "crazymakers").
Lose-Lose:
In lose-lose methods of problem solving, neither person is satisfied with the
outcome. While this might appear a rather discouraging approach, in fact it is
one of the most common. The most respectable from of lose-lose conflict uses
a compromise strategy. Interestingly, however, while we might find the people in
a conflict who compromise rather admirable, we view a compromise of values,
beliefs, and ideas unfavorably.
Win-Win:
In this tvpe of problem solving the goal is to find a solution satisfying to everyone
involved" The belief guiding win-win conflict is that by working^together it is
possible to find a solution with which everyone reaches his or her goal without
needing to compromise. Integration, collaboration, and problem solving are the
strategies associated most often with win-win conflict.
The "managing interpersonal conflict" technique outlines six stages or steps, each with
its specific goals and relevant skills. The emphasis is on the specific intrapersonal and
interpersonal skills necessary to successfully engage in win-win conflict. The corner
stone to the successful implementation of the technique is the development and
maintenance of a supportive, confirming communication climate.
STAGE 1:
Evaluating the conflict interpersonally. Before communicating with the other
person, the people in conflict identify what is really bothering them. Each tries
- -- •
•
What are the causes of the conflict? When
to answer the following
questions:
should the conflict be discussed? Where should the conflict be discussed?
The skills necessary at this stage are the ability to identify and describe your own
feelings and recognize that you "own" them, that is, they are your feelings.
Describing the other person’s behavior in a non-evaluative way is another necessary
skill which includes separating fact (what is observable) from inference (ascribing
"reasons" and "motivations" to the other which cannot be known from direct
experience). Finally, the ability to empathize with the other person is necessary.
At the end of this stage, you and the other person understand the conflict from
an intrapersonal perspective: You understand your own behavior and feelings, an
your perceptions of the other person’s behavior and feelings. These descriptions
are the material used as the basis for discussion during Stage 2.
STAGE 2:
Defining the conflict interpersonally. During this stage, you and the other person
share your perceptions in an attempt to uncover the nature and causes of the
conflict. Questions to be answered during this stage include: What are the
individual perceptions of the conflict? Can a mutual definition of the conflict be
arrived at?
Tire skills necessary at this stage relate primarily to developing a supportive and
confirming climate. The ability to be nonjudgmental, descriptive, empathic, and
nontangential are important support-producing behaviors. The confirming behaviors
of relevance here include owning and describing your feelings, listening actively to
the other person, and sending congruous verbal and nonverbal messages.
At the end of this stage, you and the other person have shared your perspectives
and understand how the other sees the situation. You have also come a long way
toward establishing a supportive communication climate which helps the process
of conflict resolution to continue.
STAGE 3:
Interpersonally identifying mutually-shared goals. Considered the most important
stage, the major purpose now is for you and the other person to express your
needs and desires-your ultimate goals. This stage requires the honest disclosure
of each person’s goals. This serves a variety of purposes; for example, each
person learns how far apart he is from the other person. If goals are vastly
different it may be necessary, at a later stage in the process, to alter the
relationship dramatically, or even end it.
Disclosure here may also cause you and the other person to re-examine what was
discussed during Stage 2: The new information may lead to a reassessment of
the causes of the conflict. Finally, disclosure tells the other person he is trusted
and significant, an important part of establishing a supportive, confirming climate.
The questions which you and the other person attempt to answer during this stage
include: What goals are we attempting to satisfy? Which of these goals are
mutually shared? Which of these goals are important in formulating a way to
resolve the conflict? The skills necessary to answer these questions, in addition
to those discussed under Stage 2, include the ability to identify the positive aspects
of the conflict management effort ("I’m glad we’re talking this over together.
"The fact that you want to talk this over tells me we both think our relationship
is important.") and the ability to be problem-oriented and not controlling.
At the end of this stage, you and the other person have uncovered mutually
shared goals based on your understanding of each other s needs, desires, and
individual goals.
No solutions have yet been generated, but the necessary
information has now been gathered to move on with that important step.
STAGE 4:
Interpersonally identifying a variety of .possible resolutions. Hie purpose of tnis
7tave generating solutions, is fulfilled by answering the following questions: What
are the possible ways to resolve the conflict? Have we considered all the possible
ways?
Along with the skills necessary for completing Stages 2 and 3, the following skills
are pertinent to Stage 4: The ability to communicate professionalism rather than
certainty, and the ability to refrain from premature evaluation of any solution.
At the end of this stage, you and the other person have generated a list of
possible solutions. What remains now is for each solution to be critically
examined in light of the mutually-shared goals.
STAGE 5:
Interpersonally weighing goals against possible_jTsohitions. Stages 3 and 4 are
brought together during this stage as each Stage 4 resolution is examined tor the
ability to satisfy Stage 3 goals. The questions which need to be answered include:
How does each resolution stand up against the goals? Which resolution satisfies
the greatest number of goals? Can we agree on the best resolution?
All of the skills previously mentioned are also applicable at this stage. In
addition, supportive behavior also becomes specifically relevant at this time, the
ability to react spontaneously rather than in a strategic fashion.
At the end of this stage, it may seem as if the process conflict resolution is over.
After all, the conflict has been defined individually and mutually, goals have been
established, solutions generated, and the best resolution agreed upon. To stop
now assumes that any solution is forever, that time does not change things, that
people remain constant all the time, that events never alter circumstances. Of
course this is not true, so a last step seems be included which is as relevant as
the others.
STAGE 6:
Interpersonally evaluating the chosen resolution after a period of time. The
purpose of this stage is to review the resolution from time to time and assess if
it needs to be changed, modified, or left alone. Reviewing the aspects of a
selected resolution does not mean that something is wrong and must be corrected.
Indeed, everything may point to the conclusion that the resolution is still working
to satisfy the mutually-shared goals, and that the mutually-shared goals are still
the important ones to consider.
This stage requires all the skills discussed under the other stages, plus one
additional one: The ability to be honest with yourself as well as the other
person It may be difficult for you to say, "We need to talk about this again,
and yet it may be essential if the conflict is to remain resolved. Because a
conflict resolution strategy needs to be evaluated now and again does not in any
If
way point to some personal failure on the parts of the people in conflict. L
anything, it demonstrates how realistic they are.
The six-step "managing interpersonal conflict" technique is adapted from Deborah
Weider-Hatfield, "A Unit in Conflict Management Communication Skills,"
Communication Education, 30 (July 1981), 265-273.
Also - Ronald B. Adler, Lawrence B. Rosenfeld, and Neil Towne, Interplay: The
Process of Interpersonal Communication, 2nd. ed., (New York, Holat. Rinehart and
Winston, 1983).
TRANSFORMING NEGATIVE CLIMATES: COPING WITH CRITICISM
Changing a negative climate to a positive one is like slowing down a runaway horse:
You have to stop the animal before you can begin to move toward your destination.
One of the biggest barriers to overcoming negative climates—our runaway horse—is the
torrent of negative criticism characterizing them. Two methods are available to handle
criticism constructively, without feeling the need to justify yourself or to counterattack.
The first considers seeking out more information, and the second concerns agreeing
with the person who is criticizing you.
When criticized, seek more information
1.
Ask for specifics to clarify the nature of the criticism.
2.
Guess about specifics if the other cannot provide them.
3.
Paraphrase ideas to clarify them and to draw the other person out if he
or she is confused or reluctant.
4.
Ask about the consequences of your behavior for the other person so that
you may begin to understand his or her needs.
When criticized, agree with the speaker
There is virtually no situation in which you can’t honestly accept the other person’s
point of view and still maintain your position. Arguing with the critic creates a more
defensive climate and guarantees that there will be no resolution to the conflict.
There are four types of agreement, each of which may be expressed in different
circumstances:
1.
Agree with the truth. Agreeing with facts seems quite sensible when you
realize that certain matters are indisputable. Agreeing with the judgment
may not be quite so easy. For example, "You’re an hour late, you idiot!"
may be easy to agree with on a fact level (you may indeed be an hour
late), and hard to agree with on a judgment level (you may not view
yourself as an idiot for being an hour late).
2.
Agree with the odds. If the criticism relates to a future or probable event,
agree with the odds for its occurrence. To deny another’s predictions does
\ For example, "If you
not change the other person’s mind (or your own).
don’t advertise your office, you’ll never get enough people to come in!" may
be responded to with "You’re right. There is a chance that could happen."
This agrees with the odds.
3.
Agree in principle, A criticism which comes in the form of an abstract
ideal against which youi are being unfavorably compared may be agreed with
in principle without agreeing with the comparison. For example, "I wish you
wouldn’t spend so much time on your work. Relaxation is important too,
you know." A nondefensive, agreeing response could be: "You’re right, it
is important to relax."
4.
Agree with the critic’s perception.
When there seems to be no basis
whatsoever for agreeing with the critic-there is no truth to the criticism,
you can’t agree with the odds, and you can’t even accept the principle the
critic puts forward-you may still agree with the critic’s right to perceive
things as he or she does. For example, ”1 don’t believe your office is as
busy as you say it is. You’re probably making it up so I’ll think you’re
fantastic.” A nondefensive, agreeing response could be: ’’Well, I can see
how you might think that. I’ve known people who lie to get approval.”
Adapted from:
i
Ronald B. Adler, Lawrence B. Rosenfeld, and Neil Towne, Interplay:
'The Process of Interpersonal Communication, 2nd ed. New York.
•
MUNDANE BARGAINING STRATEGIES adapted from David Johnson and Frank Johnson,
Joining Together (Englewood Cliffs, NJ: Prentice-Hall, 1975).
171
WIN AND LOSE - WHAT STRATEGIES TO ADOPT
Win-Lose Strategy
Bargaining Strategy
1.
Define the
problem.
conflict
as
a
mutual
1.
Define the conflict as win-lose.
Pursue one’s own goals.
Force
the
submission.
I
2.
Pursue goals held in common.
2.
3.
Find creative agreements that are
satisfying to both parties.
3.
4.
Have
an
accurate
personal
understanding of one’s own needs and
show them correctly.
4.
Have an accurate understanding of
one’s own needs, but publicly disguise
and misrepresent them.
5.
Try to equal power by emphasizing
mutual interdependence, avoiding harm,
inconvenience,
harassment
or
embarrassment to the other.
5.
Try to increase power over the other
party
by
emphasizing
one’s
independence from the other and
other’s dependence upon oneself.
6.
Make sure contacts are on the basis
of equal power.
6.
Try to arrange contact where one’s
own power is greater.
7.
Use open, honest, and accurate
communication of one’s needs, goals,
and position.
7.
Use
deceitful,
inaccurate,
and
misleading communication of one’s
needs, goals, and position.
8.
Accurately state one’s needs, goals,
and position.
8.
Overemphasize one’s needs, goals and
position.
9.
Work to have highest empathy and
understanding of another’s position,
feelings, and frame of reference.
9.
Avoid all empathy and understanding
of other’s position, feelings and frame
of reference.
10.
Communicate
orientation.
problem-solving
10.
Communicate win-lose orientation.
11.
Avoid threats in order to reduce
other’s defensiveness.
11.
Use threats to get the submission of
others.
12.
Express hostility to get rid of feelings
that might interfere with future
cooperation.
12.
Hostility
others.
13.
Behave predictably through flexibility.
13.
Behave unpredictably to make use of
surprise to trick others.
14.
Change position to accommodate needs
of the other.
14.
Concede and change
concessions a<*e made.
a
is
other
f'7
party
into
I
expressed
to
only
subdue
when
b
1
15.
Promote clarity, predictability,
mutual understanding.
and
15.
Try to increase ambiguity and
uncertainty to confuse the issue.
16.
Use cooperative behavior to help
establish trust.
16.
Use cooperative behavior to exploit
someone else’s cooperation.
17.
Seek exploration of other’s similarities
and differences in positions.
17.
Emphasize the differences to make
use of your power position.
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