Associate Advisor, NHS Education for Scotland (West Region)
Peter McCalister MB ChB DRCOG DCCH Dip Med Ed
Practice Based Small Group Learning (PBSGL) (Scotland) Education Lead
Ronald MacVicar MB ChB FRCGP DRCOG DCCH
Director of GP Education, NHS Education for Scotland (North Region) and PBSGL (Scotland) Programme Lead
Received date: 9 June 2010; Accepted date: 28 November 2010
IntroductionPractice-based small group learning (PBSGL) originated in Canada and has spread to Scotland. After a successful pilot in 2004, there has been rapid growth in the number of participants in Scotland, particularly among general practitioners (GPs). Growth of participant numbers has required the recruitment and retention of trained peer facilitators who help PBSGL groups to learn. It was not known what the perceptions and experiences of PBSGL facilitators were; in particular what had motivated them to become and continue as facilitators. MethodTwo focus groups of PBSGL facilitators were held; their discussions were audio-recorded and transcribed with permission. Data generated were coded, and themes were constructed from these codes. ResultsParticipants found facilitation work to be enjoyable and useful. They had positive past experiences of problem-based learning and of small group learning. Older facilitators had experiences gained through their involvement in GP registrar training. Some of the younger facilitators saw the programme as being a method to enhance and advance their careers. There were anxieties about recruiting new PBSGL groups from potential members relatively unknown to facilitators. Once groups were established, facilitators felt there was little need for further support. DiscussionParticipants were enthusiastic about PBSGL facilitation, suggesting that the programme will continue and may grow further. Their positive perceptions and experiences should reassure potential new facilitators.
continuing professional development, facilitation, problem-based learning, small group learning
Practice based small group learning (PBSGL) started in Canada and has been previously described.[1–3] The programme uses learning modules derived from problem-based learning, and aims to drive evidence into clinical practice. Small groups of clinicians (usually between five and ten members) meet to discuss cases, reflect on the evidence base in the module and con-sider what changes they may make to their own practice. Groups usually meet in the evenings and select from an extensive list of modules. The number of meetings varies from group to group, but would commonly be from six to ten per year. Venues used by groups vary, but include general practice premises, post-graduate education centres, hotels and partici-pants’ homes. Group members’ discussions and learn-ing are facilitated by trained peer facilitators. The programme has been shown to be well accepted by participants and can result in changes in knowledge and in patient care.[5,6]
The programme was introduced to NHS Scotland in 2004 with a pilot study of 36 general practitioners (GPs) in five geographical areas. The pilot study was evaluated using quantitative and qualitative methods and judged to be successful.[7,8] After the pilot period PBSGL became available to all GPs, practice nurses and community nurses throughout Scotland. It spread quickly, and now involves 740 members in 84 groups in Scotland; all 14 NHS boards in Scotland have at least one group, most consisting of GPs. There are some mixed groups of GPs and practice nurses, and a few practice nurse only groups. The PBSGL programme in Scotland is supported by NHS Education for Scotland (NES) a special health board with responsibilities for NHS workforce development and learn-ing.
The important role of the peer facilitator has been highlighted in previous research. That research also found that a significant number of PBSGL members did not feel able to take up the role of facilitator, although this role is open to all PBSGL members. In accordance with the parent programme in Canada, PBSGL groups are formed and continue with the support of a peer facilitator. In Scotland, facilitators must attend a mandatory one-day training event (phase one) and are offered regular follow-up half-day train-ing events (phase two). PBSGL facilitators are not paid a fee for their work for the group, but in recognition of their work they are not charged the annual member-ship fee for the PBSGL programme.
Although PBSGL membership has dramatically increased in NHS Scotland in the last few years, a significant waiting list of potential members had developed. Clinicians are unable to join or form a new group until a facilitator has been recruited and trained. A number of individuals had volunteered to train as facilitators at regular training events, but there was hesitation amongst some on the membership waiting list to become facilitators. It was not known why.
The aim of the study was to understand the per-ceptions and experiences of those members who had trained as facilitators and who continued in this role, and in particular to:
• learn what motivated them to become a facilitator
• learn what motivated them to continue as a facilitator
• consider their perceptions of why their colleagues who are PBSGL members had not themselves become facilitators.
Research participant recruitment
Trained facilitators who had arranged to attend a phase two event for facilitation training were contacted by an email from the first author. They were invited to join a research focus group at the end of the training event. The email contained a copy of the research proposal for information, and a consent form. Focus groups were arranged in venues independent from NES; one health centre in the West of Scotland and a hotel in the East of Scotland were used. Recruitment to the study ended when data saturation was achieved.
Focus groups were moderated by the first author. He had received training in moderating focus groups and was experienced in this work. An interview guide was drawn up to structure the focus groups; open-ended questions were used to encourage participants to describe their experiences and to be interactive with other participants. The questions are shown in Box 1. An iterative process was employed: themes arising from the first focus group discussion influenced the questions posed to the second focus group. Partici-pants were asked to record how long they had worked as a PBSGL facilitator, and the length of time since they had attained their professional qualification.
The focus groups were audio-recorded with per-mission of the participants, and the recordings transcribed. Transcriptions were then checked against the original audio-recordings and corrected. Tran-scriptions were read and re-read.
method of coding approaching the grounded theory methods described by Charmaz was used. Codes were developed which captured phenomena and social processes. Codes were examined and themes constructed. Codes and themes were compared using a constant comparison method to draw out contrasts and similarities. Memos were written which attempted to capture the themes and evolving concepts from the data, and to contribute to the data analysis process.
The study findings were sent to focus group par-ticipants for their opinions on whether they accurately reflected their perceptions and experiences of being a facilitator.
Two focus groups were held between April and June 2009. Eleven out of a potential 28 facilitators who attended the phase two facilitator training events took part; there were six and five participants respectively in the first and second focus groups. Participants were drawn from five different health board areas in NHS Scotland. All were GPs. Inconvenience and lack of time were cited by those facilitators who were unable to participate. Focus groups lasted for 39 and 45 minutes.
Participants were sent the research findings for their approval; eight out of 11 replied. All agreed that their perceptions and experiences had been represented.
Participants were diverse with regard to time since professional qualification, length of time since their initial facilitator training and their roles in primary health care. Five participants had been qualified for between six and ten years, and six participants had been qualified for between 24 and 35 years. Partici-pants from these age ranges were represented in both groups.
Positive past experiences of small group learning
Facilitators had many positive experiences of the effectiveness and enjoyment of learning in a small group. This was one of the strongest motivators to becoming and remaining a facilitator; PBSGL was a proven learning method in their own eyes. Some of the more recently qualified participants had experience of small group learning and problem-based learning at their medical schools. As a consequence they were very familiar with these learning methods. Others had been exposed to these methods not at medical school but during their GP registrar teaching, and felt it was likely to be a preferred learning method for the future GP.
For a few participants the benefits of continuing peer support was one of the reasons they had chosen to train as a facilitator. They were keen that their pre-viously formed group should continue, and they saw PBSGL as a way of enabling it to do so. As someone from this group was needed to train as a facilitator, it was a natural choice for them to volunteer as they felt enthusiasm both for this form of learning and for the support of their existing group.
‘For me it was having a group already formed (GP registrar group) really, but being aware that we wanted to do something a bit more structured and something educational rather than just meeting for a social chit chat. So it provided an opportunity to do that.’ (Group One, Participant Five)
‘I’d already had my free form study group that was a continuation with additional members from my registrar group which had just come to an end that year. And at the end of our registrar year we wanted to have a continuation of that support network and a way of continuing our professional development. And our studying, we had worked well as a, in that kind of sort of small group forum.’ (Group Two, Participant One)
Participants considered that if a PBSGL group was to be established, it would be necessary for them to take the lead in the recruitment and organisation of a new group and volunteer to become the facilitator.
‘I suppose I was ... I was the person who had the most access to information about PBSGL through my job at NES. And also I was probably the main, I don’t know, proponent and of wanting to get it done and kind of probably the most enthusiastic about it.’ (Group One, Participant Six)
Other participants who were more experienced GPs also shared this motivation. They too were familiar with small group learning and were keen to become PBSGL members. They realised that unless they vol-unteered to become facilitators, a new group would not form in their area. Other participants gained from being in regular contact with peers and expressed the benefits of the reduction in isolation.
‘For me it was isolation, because I am working as a locum. Well I could see myself becoming quite isolated working as a locum for some time so I wanted to have some form of ongoing educational development but also get some peer support as well.’ (Group One, Participant One)
Some older or more established GPs had become familiar with facilitated small group learning not through their medical school education but by being attached to GP trainers’ groups. There were acknow-ledgements that this was an effective learning method and one with which they had become familiar through their role as a GP trainer.
‘As far as facilitating goes, I guess I’d done quite a lot of one-to-one stuff, one-to-one with student teaching, one-to-one as a trainer, been a trainer for a number of years. And I had done some small group clinical teaching.’ (Group Two, Participant Three)
‘As a learning activity I think it is really, I think it is great. I mean, I like the way it works, it’s the networking, the team working and the interaction. It (being a facilitator) isn’t a huge amount of work, and you get so much from your colleagues’ experiences and things you can share. I am going to continue facilitating because I want to continue.’ (Group One, Participant Three)
Learning new skills
Participants were interested in becoming facilitators as they saw it as a further development of themselves. It was adding new skills to existing ones. The oppor-tunity to have facilitation training at no additional cost was taken up in recognition that it provided personal development and growth and some saw these new skills as being transferable to other situations and groups.
‘Well I was looking for other strings to my bow as it were, to try to develop what I do beyond my sort of salaried role.’ (Group Two, Participant Four) peers and the PBSGL module, and to learn how to facilitate.
‘Learning in two places for me; as a GP and for me in medical education.’ (Group One, Participant Three) Participants perceived that it was a commonly held belief amongst non-facilitating PBSGL members that these skills were hard to achieve.
‘And I suspect it’s probably more something to do with the mysticism that surrounds small group work and small group working and you’ve got to be some kind of guru to be a small group facilitator and all that kind of nonsense.’ (Group Two, Participant Two)
Younger participants had similar thoughts on the addition of new skills as their older colleagues, but their motivation to learn new skills was different. Younger participants saw the role of facilitator as one that would help them progress within the career structures of general practice: gaining a partnership in a practice or increasing their potential to find locum work in an area. A few saw the role as helping them in their bid to develop a successful career in GP medical education.
‘It also helps me with my sort of career aspirations. I suppose in medical education as well.’ (Group Two, Participant One) Being part of a social network of GPs was seen as beneficial to the chances of getting further employ-ment:
‘But I’m also just kind of mindful of my roles in the future and just networking and social and support that I need. And these would be the main things.’ (Group Two, Participant Four)
‘I’m not able to work a bit more and I would like to, I would like to work a bit more and I’m just not able to do that right now. And so just I need to kind of, keep my options open for the future and I think it is just a good thing to do (for career advancement).’ (Group Two, Participant Four)
One participant described how she had joined a new partnership in general practice, and that her skills as a PBSGL facilitator had been welcomed and valued by her new partners:
‘Interestingly my, the partners that I’ve just applied for, the two of the partners are members (of PBSGL) but not facilitators and they’ve obviously not thought about being facilitators. But they were very impressed with the fact that I was a facilitator.’ (Group Two, Participant Four)
One participant saw the advantages of being a facilitator as being dual purpose: to learn from his
Anxieties about recruiting de novo groups
A common sentiment amongst participants was their anxiety about forming a completely new group, or at least a group that contained a significant number of participants who were relatively unknown to each other and to the facilitator. They felt this perception was also commonly held by PBSGL members who were hesitant at becoming facilitators:
‘I wonder if that might be quite daunting. I mean certainly even for us, you know a bit of anxiety is bringing in people to the group. I suppose for me as well I’ve a group that’s relatively well formed and bringing in new people who may have different personalities. It’s that fear of meetings I suppose. Like anybody in such a situation, meeting strangers and ‘‘Are we gonna get on and ...’’’ (Group Two, Participant One)
It seems that PBSGL groups had formed in various ways. One common method was of pre-existing groups such as those of GP registrars, retainees or GP locums evolving into PBSGL groups. PBSGL was popular with the latter two groups as it helped them remain up to date and to meet their learning needs. Some participants had missed their previously supportive GP registrar group and saw PBSGL as a way in which this group could continue to meet, network and learn with each other, and to enjoy each other’s companionship.
Other groups were recruited less formally and they consisted of partners from the facilitator’s practice and other friends and colleagues who lived in the locality. A third method involved the recruitment of potential members from the wider community of practitioners by emailing all the GPs in one area, in the hope that there would be enough interest to start up a new group.
It was this method which caused most anxiety. Some participants felt that this method discouraged colleagues from training as facilitators as they were anxious that a new group would be hard to start, or would encounter problems and fail. There seemed to be a second concern; that once trained as a facilitator, a recruitment drive for potential PBSGL members from among local practitioners was expected, to be led by the newly trained facilitator. Other participants were less anxious about this. They were aware of a strong demand from their local colleagues to join PBSGL groups as members, and that their fellow GPs seemed reluctant to train as facilitators. One participant felt that her application to train to become a facilitator would be warmly received by local colleagues and that there would be little competition from others.
Being a facilitator is both useful and enjoyable work
A commonly held perception from participants was that they perceived being a facilitator was personally enjoyable, but also very useful for their small group.
‘I think they (PBSGL group members) benefit from it. I don’t think it is necessarily essential, you know if the facilitator was absent or somebody who normally facili-tates. I think the group would function fine for a meeting or two. But I think in terms of keeping to the evidence and the cases and so on, it is important to have somebody just to guide things along. Make sure everything is covered.’ (Group One, Participant Five)
‘I think you need a facilitator certainly need it for the donkey work of the, arranging the meeting and making sure everybody has the module. As for within the meeting, I think if you didn’t have a facilitator somebody from within the group would probably adopt that role. Where if they didn’t see themselves as a facilitator, I think a lot of people might miss out certainly in our group, a lot of the quiet people who probably need encouragement to speak up.’ (Group One, Participant Four)
‘And I think, you know, even if that is the only role a facilitator performs, I think it’s valuable.’ (Group One, Participant Two)
Facilitators found the workload of being a facilitator easier than they initially thought and that their free membership of the PBSGL scheme recompensed them for the time and effort.
Some facilitators had considered the delegation of some key tasks to group members; organising venues and dates, and communication with the PBSGL ad-ministrator. Participants perceived that once estab-lished, PBSGL groups needed little facilitation and that after some years their work had become invisible.
Participants perceived that their official role gave them the right to challenge opinions in the group and that as a trained facilitator the group gave them the authority to challenge or to keep the group focused on the learning tasks within the set time.
‘It gives you licence to play devil’s advocate as well and challenge people a bit more whereas if you were always doing that as just a group member, people might think you were just doing it to annoy them.’ (Group One, Participant Two)
A few participants recognised that being a facilitator encouraged them to undertake a deeper learning of the module. They were conscious that they were not there to tutor or teach their group members but they wanted to have a good understanding of the issues raised in the module. Being a facilitator was a way of encour-aging them to read through the module thoroughly before attending the learning event.
Support for facilitators after initial training
Participants felt there were several methods that could be adopted that might provide trained facilitators with ongoing support. This was perceived to be of value in the early months and years of facilitation work. One solution was mentorship. Participants considered that one-to-one mentorship with an experienced or estab-lished PBSGL facilitator would be very beneficial. This was also suggested as a method to encourage members of existing groups to train as facilitators. An online forum or an email support group were also sugges-tions for supporting new facilitators.
Another suggestion was of shared facilitation, where two or more facilitators would alternate facilitation within one PBSGL group. Participants felt this could help with the facilitation workload and reduce the sense of commitment to the PBSGL group.
‘For me I was quite new in the job and where I was working there was already a facilitator in the group. But having a second person as a co-facilitator is quite handy for the group. And it is a pretty small, close, close group of the area and then it is already well established. So it is just quite good for the opportunity to do, to be trained and have some, some extra sort of educational activities.’ (Group One, Participant Five)
Some participants viewed their commitment to the group as a facilitator as being a positive factor; it kept them learning and made sure they attended as a facilitator and a learner. Their need for ongoing support was lessened as a result.
‘Yeah I think, I think people are always a bit wary of a commitment and that it ties them down. I mean for me it kind of worked, what was in fact one of the reasons why I maybe took the push to make me decide to become a facilitator was that commitment.’ (Group Two, Partici-pant Four)
‘So I think that’s for me, the appeal of facilitating, because I know it will force me to keep, keep up with doing it.’ (Group Two, Participant One)
More established facilitators reflected on their role within their group and felt that their work had become easier with the passage of time. They considered that their group members had become comfortable with each other and had learned how best to interact with each other, in order to benefit from small group learning. Again, they felt there was less need for them for formal ongoing support for their role as facilitator.
‘I think it’s, it depends very much on the group as ... says. And I am sure lots of groups and probably my own group as an example get to a stage where, where they know the rules of the game, they know what they’re doing.’ (Group Two, Participant Two)
‘Also a good facilitator particularly if they are more, different type of styles of facilitation but if that person’s particularly, perhaps a reflective quieter person, that facilitation may be very effective but be invisible to somebody from the outside.’ (Group Two, Participant Three)
This study aimed to gain an understanding of the perceptions and experiences of PBSGL facilitators, and to understand why participants had become and remained facilitators within the project; these aims were achieved. In particular, facilitators talked about their concerns in recruiting members to new groups and described the various methods that achieved this. This had not been described before and is important given the fast growing nature of the programme. It will be useful for future peer PBSGL facilitators to gain from earlier experiences. The research also illumin-ated the background of facilitators. It was apparent that facilitators in this study fell into two distinctive age ranges. The younger facilitators had been qualified for between five and ten years, and some of them were keen to pursue a career in both general practice and medical education. Some of this group had also been educated using small group learning and problem-based learning formats. The second group was con-siderably older (having been qualified between 24 and 35 years); some of them had considerable experience in postgraduate teaching and GP training and had gained knowledge of new learning methods in these posts. It is not known whether these two distinct age ranges are replicated throughout the PBSGL Scotland programme.
If the programme was to spread further in Scotland and to the rest of the UK, it would be prudent to initially target the recruitment of individuals with similar backgrounds and experience. They would be more likely to be early volunteers as PBSGL facilitators.
There were several strengths of the study. The quali-tative research design gave results that were rich in the experiences and perceptions of facilitators. Partici-pants talked openly and honestly about their facili-tation work. Participants in the study were diverse; both in the length of time since professional qualifi-cation, but also in the period they had worked as PBSGL facilitators. This ranged from three months to five years – when the pilot project began in Scotland. Participants also held diverse roles within general practice and included principals in general practice, locums, clinical assistants and research fellows. The participants were drawn from five separate NHS boards within NHS Scotland. PBSGL groups were based in cities, towns, rural areas and isolated islands. This may enhance the transferability of the research results to other areas in Scotland and to the rest of the UK.
There were limitations to the study. Focus groups were used as the method of data generation; using other interview methods such as in-depth interviews would have been an alternative method of data collec-tion but would have proved costly due to the reim-bursement of medical time. Participants who attended the phase two training event may have been different from those facilitators who did not attend; they may have been more enthusiastic about the programme. Only GPs responded to the invitation to be involved in the research. None of the small number of practice nurse facilitators in the PBSGL programme responded to the invitation, and thus their perceptions and experiences remain unknown.
This study adds to the research about small group learning facilitation and in particular gives the per-spective of peer facilitators. Participants were predom-inately working in clinical practice and were peers of the PBSGL members. Other research has described and analysed the role of small group and problem-based learning facilitators who have an academic background, or who perform small group facilitation or tutoring as part of their duties in medical schools or other higher education establishments.[12–15] One re-search finding, the desire for career advancement as motivation to become a facilitator, is in keeping with previous research. This study is concerned with primary healthcare practitioners and with peer facili-tators in a long-term learning programme; little has been published regarding this group.
Facilitators had diverse motivations that made them decide to become facilitators and to continue with this work. In order to most effectively spread PBSGL to other healthcare practitioners and to other areas, the rewards of being a facilitator need to be understood and disseminated.
Any anxieties that potential facilitators may feel – mainly the concern that a new group will be hard to form, or will be dysfunctional – need to be discussed with potential facilitators before and during the initial training. Facilitators of such groups will need the most support especially in the earlier years. There are many potential members of PBSGL groups who would warmly welcome the presence of a new facilitator in their locality, and this information should be dissem-inated so that potential facilitators can be recruited.
Facilitators gave positive responses about their experiences as group leaders, which suggests that the project should be able to continue in the long term as a vehicle to drive evidence into practice. The experience of our sister programme in Canada, where individual facilitators have continued to lead groups for many years, even in areas of geographical isolation, encour-ages us to continue to spread the programme through-out the UK.
We are grateful for the contribution of the research participants and to Diane Kelly from NES (West Region) for feedback and critical input. We are also grateful to Debbie Brumby for transcription work.
This study received no Funding from any source.
The research proposal was submitted to the Lothian MREC Committee, and deemed by them not to require formal Ethical Approval as the study was an evaluation of an existing service.
Not commissioned; externally Peer Reviewed.
David Cunningham and Ronald MacVicar are employed by NES. Peter McCalister is employed by the PBSGL programme.