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Facilitating small group learning in the operating department.


The majority of staff in the operating department are likely to have been through a school education system that creates passive students who become dependent upon the person teaching them to provide them with information. Although higher education has made some inroads into turning learning into a more active process, it is only in clinical practice that learners are required to participate fully in their learning in order to gain specific knowledge and skills.

Learning is closely associated with the operating department with its high ratio of registered to unregistered staff. Although structured learning for nursing students and operating department practitioner students is commonly planned as a programme, at times learning for registered and unregistered staff can be ad hoc and unplanned. Therefore, there is a need to organise it to ensure that learning experiences are maximised. Learning through small groups is a flexible process and this paper proposes that it can optimise learning for all levels and types of staff in the operating department. The next sections will outline the strengths and limitations of small group learning generally followed by three different types of small groups as examples of how learning can be facilitated.

Small group facilitation

Being a facilitator

The facilitator may have another role as the small group may have been convened for a specific purpose. For example, the facilitator may be a mentor charged with ensuring a group of learners complete specific competencies related to the operating department. The facilitator may also be the supervisor, manager or even a researcher of the group. Any one or combination of these roles will affect the dynamics of the group. For example, a manager facilitating a group may be expected to come with all the answers to any problems which arise. The manager as facilitator could also inhibit group discussion and group problem-solving. Any other roles attributed to the facilitator should be taken into consideration when planning the group session.

Letting go

Gray (2000) claims that an effective facilitator needs to possess appropriate professional attributes, knowledge, communication skills and motivation to support learners. Having a suitable philosophy is also important as small group learning emphasises a nondirective rather than didactic teaching approach (Bastable 2008). Bastable encourages facilitators not to view themselves as transmitters of content but as coordinators of learning centring on the learner.

Letting go in this way can be challenging to those used to teaching didactically. This is especially so if the facilitator is a novice as facilitation creates a climate of enquiry where barriers between 'teacher' and 'learner' are removed. This can make the facilitator feel vulnerable to questions, which they may not feel able to answer. However, if when letting go via facilitation an adult-adult relationship is formed rather than the parent-child relationship of didactic teaching (Jacques 2000), then it removes the responsibility from the teacher to be the 'fount of all knowledge'. Facilitators may also have concerns that through facilitation learners may not learn what they need to know (Doring et al 1995). This can be addressed through 'scaffolding' where the underpinning knowledge of learners is established and dependence on the facilitator is gradually reduced (Bruner 1977).

Building trust

Rogers and Freiberg (1994) identified principles for effective facilitation including the use of student ideas, open discussion of issues and regular praise of learners which should assist in establishing trust in a small group. Ground rules are also essential in any small group as they provide a guide to all participants. The ground rules can be predetermined or developed by the group as part of their induction. Like all rules, they should be revisited regularly to ensure that they remain relevant and achievable and do not unnecessarily constrain learning. Confidentiality within the group can help to establish trust in a small group and is usually one of the fundamental ground rules (Butterworth et al 1998).

It is likely that the facilitator will be familiar to learners as a practitioner in the operating department. By acting as a role model and by building up a trusting, credible relationship in practice the facilitator will be able to promote learning more readily. The facilitator should create a safe environment that encourages open discussion in the group. The facilitator may need to use such tactics as positive reinforcement to establish a rapport with group members.

Freedom to learn

Carl Rogers (1983) coined the phrase 'freedom to learn' and this captures small group learning at its best. Creating a learning environment where experiences can be explored and discussed will allow the learner to self evaluate and understand what they want and need to know.

With the right type of facilitation, the student should be able to develop creative approaches to care, develop a curiosity around the subject and nurture an interest in the topic of study, which sits well with the current ethos of life long learning and continuing professional development in light of the Knowledge and Skills Framework (Department of Health 2004).

Challenges of small group learning

There will undoubtedly be individuals who feel inhibited in a group situation. This type of person may not feel able to ask questions in front of more senior or more experienced colleagues. It would be the remit of the group facilitator to recognise this and take remedial action as necessary.

Being accountable for practice extends to teaching and learning. If a person has attended a small group to learn is it possible to ensure that learning has taken place? Assessment of learning can be assured in several ways: Testing the participants is possible and may be appropriate in certain situations. In other circumstances, it may be appropriate for the facilitator to observe the clinician's practice following the small group session to ensure that learning has taken place. A more student-centred approach to assessing learning could include exercises to complete for inclusion in the learner's professional portfolio.

Learning through small groups

Small groups are a more appropriate size for learning in the operating department as larger groups would tend to deplete the teams and compromise workload. Depending on the group size and length of time allocated to learning, they enable interaction between all participants which can be rewarding for all (Quinn 2000).

A group may be formed for a specific purpose such as demonstration of a new surgical technique, or it may be ongoing such as a group of student ODPs, which may remain as a group during a period of training (see the three examples later). Lawrence (1986) suggests that ongoing groups go though a series of stages as they develop which reflect progression from acquaintance to being productive in a task (Table 1). To enable learning, each stage will need to be addressed as it occurs to ensure the cohesiveness of the group. The progress of group development and the relevance of Table 1 would be influenced by the time available and the purpose of the group. Planning small group learning is essential and the learning style should be tailored to meet the purpose of the group and its members (Quinn 2000). The physical environment should be pleasant and comfortable with the least amount of distraction and interruption. Seating should be arranged to enable interaction and reduce the potentially threatening nature of learning with a small number of people. Although there may not be allocated education facilities within the operating department, informing colleagues of the session and placing notices outside the venue will help to minimise disruption of learning.

Small groups enable learners to express themselves and develop knowledge of a subject in a non-threatening environment. However, there will inevitably be differences in the amount of effort expended by individual group members. This must be monitored by the facilitator to avoid 'social loafing', a term developed from a study where the effort of individuals in a team pulling on a rope was measured. It was found that the more group members there were, the less effort some individuals expended (Pennington 2002).

As individuals, learners have various ways of learning and awareness of the learning styles of group members is important, as it will help the facilitator tailor the session appropriately (Table 2). In certain situations, it may not be possible to accommodate all learning styles, but knowing that people learn in different ways will help the facilitator to vary the delivery. Assessment of learning styles could be a useful 'icebreaker' as an initial small group exercise or used as 'homework' between group sessions (Jasper 2003).


There are various ways in which small groups can be organised in order to maximise learning and three of these will be outlined below.

Mandatory training

This type of small group is run to ensure that staff have all the knowledge and skills necessary for the safe running of the operating department and will include such topics as resuscitation, health and safety issues as well as introductions to new policies, guidelines and legislation. Mandatory training has a fairly didactic remit in that it will be necessary to impart a certain amount of information in a given length of time to fulfil mandatory requirements.

Participants would normally be expected to demonstrate their learning in some way for example via a test. The amount of mandatory training required annually means that the opportunities for interaction may be limited, but should not be precluded entirely. Table 3 (adapted from Quinn 2000: 365) shows how learning outcomes for a small group undergoing mandatory training can be broken down to ensure progressive learning.

Clinical supervision

Reflection has long been advocated in healthcare and can be undertaken as an individual or in a small group (Benner 1984, Schon 1983). The purpose of reflection is to look back at one's practice and learn from the experience. Two commonly used reflective models are outlined in Figure 1 and Table 4 and show that, through asking a few simple questions, learning can be stimulated. Taking reflection into small groups can extend reflection beyond the self to include the benefits of other viewpoints and perspectives (Rolfe et al 2001).

The term 'supervision' evokes ideas of discipline and criticism (Butterworth et al., 1998) but in this instance the term clinical supervision is used to denote guidance and assistance. Clinical supervision has had a chequered history in healthcare with some professions such as psychiatric nursing and psychotherapy employing it and others studiously ignoring it. It is advocated here as a method of small group learning defined as 'a designated interaction between two or more practitioners, within a safe/supportive environment, which enables a continuum of reflective, critical analysis of care, to ensure quality patient services' (Bishop & Scott 2001: 8).

Clinical supervision, can be undertaken on a one to one basis but given resource constraints it is advocated here as a small group activity. Hawkins and Shohet (2000) identified a number of advantages of working in groups. The peer support of the group and peer feedback enhances the range of ideas generated to aid learning. This exposes each individual to a wide range of knowledge and life experiences of the other members.

Several elements need to be in place for effective clinical supervision (Table 5). Proctor's (1986) model is a useful one to use as a framework for small group learning as it addresses the normative, formative and restorative functions of practice.

The normative function enables a practitioner in the group to bring a clinical governance, management, standard-setting or professional issue of concern. For example, a member of staff may want to share a 'near miss' regarding resuscitation of a patient knowing that s/he will be able to work through the challenges of the event in a supportive environment.

The formative function involves meeting the education and development needs of the group members. Clinical supervision is an ideal environment for practitioners to explore the application of recent post-registration courses undertaken. Formative supervision could also enable an individual to consider their personal development plan or their quest to pursue a gateway via the Knowledge and Skills Framework (DH 2004).

The restorative function provides support for those working in the demanding environment of the operating department. Although the clinical governance issues of the near miss may be resolved via normative supervision, there may be personal repercussions such as loss of confidence and increased stress. Creating support for practitioners via restorative supervision could make the difference between temporary stress and burnout (Edwards et al 2005). There is a caveat that providing restorative support for professional issues is acceptable whilst attempting to solve personal challenges, however closely entwined with practice, is out with the remit of clinical supervision.

The framework outlined by Proctor (1986) can be adapted by those using it. For example, the restorative function of clinical supervision could be the focus for one session, or all three functions may merge in a complex learning situation.

Action learning

Action learning is a powerful form of problem solving combined with intentional learning in order to bring about change in individuals and the organisation. Revans (1998), attributed with developing action learning, stated that 'there can be no learning without action and no action without learning'. It is based on the relationship between reflection and action. Thinking through past events helps us implement more effective action in the future. Essential elements of action learning are tackling real tasks in the real world and the real role, learning with and through each other, taking individual responsibility and actually implementing solutions and plans. Although there are similarities between clinical supervision and action learning, indeed they both have their origins in empowering the participants, action learning stems from an organisational problem-solving base.

At the heart of the process is the 'action learning set'. This is a group of about 10 individuals who meet at regular intervals for each member to explore a challenging open-ended problem or opportunity. Every member in turn works on his or her 'task' and the others as colleagues provide support and challenge. The aim is to help each member both to tackle the task and to learn from this.

A premise of action learning is that learning has two elements: programmed knowledge (traditional instruction or knowledge in current use) and questioning insight of a situation. This is expressed in Revans' equation

Learning = programmed knowledge + questioning insight (L=P+Q)

By using the knowledge and experience of a small 'set' of people combined with skilled questioning individuals are enabled to reinterpret old and familiar concepts and produce fresh ideas, often without needing new knowledge. In the operating department this may involve an action learning set being set up to solve different problems. For example regarding implementing resuscitation a 'set' would be formed, with membership being considered carefully to ensure all stakeholders were involved. For example, a patient representative would add value to the set. The action learning cycle (Table 6) will then be followed to enable learning and action to occur.


Learning in small groups is not limited to being a vehicle for learning about a subject or skill but allows individuals to develop cooperation skills which enhance working life (Jacques 2000). In an acute environment like the operating department time-out via small group learning can boost morale as well as create a learning culture.

Small group learning has been explored as a form of facilitation, with three types of small groups being examined in relation to their function in learning. It is argued that this is possibly the most effective way of learning in such an intense and diverse environment as the operating department.

Provenance and Peer review: Unsolicited contribution; Peer reviewed.


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Dr Allyson Lipp

RN, WNB176, MA (Social Ethics), PGCE, MSc

(Social Science), PhD

Principal Lecturer, Faculty of Health, Sport and

Science, University of Glamorgan

Alex Holmes

RN, WNB176, Dip (Infection Control), BSc, PGCE

Senior Lecturer, Faculty of Health, Sport and

Science, University of Glamorgan

Correspondence address: Dr Allyson Lipp, Faculty of Health & Sports Science, University of Glamorgan, Pontypridd, CF37 1DL. Email:
Table 1 Group development

* Forming

* Storming

* Norming

* Performing

* Informing

Lawrence (1986)

Table 2 Four categories of learning styles (Hinchliff 2004: 73)

Activists       Reflectors         Theorists          Pragmatists

Like novelty    Like time to       Analyse            Learning
                think              situations         dictated by
                                                      rather than

Energetic       Thorough           Systematic         Receptive to new

Easily bored    Avoid reaching     Have the ability   Like things to
                speedy             to reason          happen quickly

Open-minded     Are observers as   Need to know
                opposed to         logic behind
                leaders            actions and

Enjoy working

Live for the

Table 3 A framework for planning small group learning
(adapted from Quinn, 2000: 365)

                                        Application in operating
                                        department based on a new
                                        procedure for checking patient
Taxonomic level     Description         consent

1 Exposure          Conscious of        I observe the new procedure
                    an experience

2 Participation     Deciding to         I take part in resuscitation
                    become part of an

3 Identification    Union of learner    I become competent in
                    with what is to     resuscitation
                    be learned

4 Internalisation   Experience          Being on the resuscitation
                    continues to        team is part of my daily
                    influence           routine

5 Dissemination     Attempt to          I teach others to resuscitate
                    influence others

Table 4 Borton's model of reflection (cited in Rolfe et al 2001:35)

What?                  So what?                Now what?

Descriptive            Theory and knowledge    Action-oriented level
level of reflection    building level of       of reflection

Table 5 Necessary elements for effective clinical supervision

* Trained clinical supervisor

* Clear boundaries for process of supervision

* Ground rules established

* Discussion within the bounds of relevant regulatory framework
 (eg NMC)

* Confidentiality

* Openness of participants

* Trust within the group

* Willingness to learn

Table 6 Action learning cycle

1. Experience--this is clinical

2. Reflection and understanding--this
takes place in the action
learning set

3. Planning action--this is done after
the set based on newly formed

4. Testing--trying out planned action

5. And then repeat step 1 and so on ...
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Title Annotation:EDUCATION
Author:Lipp, Allyson; Holmes, Alex
Publication:Journal of Perioperative Practice
Article Type:Report
Geographic Code:4EUUK
Date:May 1, 2009
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