Motivating medical students to learn teamwork skills

Abstract

Background: This study examined teaching teamwork skills to first-year medical students. Teamwork skills focused on verbal communication in PBL-tutorial sessions and in healthcare teams.

Aims: The aim was to find out how to teach teamwork skills to first-year medical students and how to motivate them to learn these skills.

Method: Three consecutive classes of first-year medical students (N = 342) participated in teamwork skills module in the years 2006, 2007 and 2008. After the first year, the introduction to the topic was revised in order to be more motivating to medical students. After each module data were collected with a feedback questionnaire containing numerical and open questions. By analyzing the students' numerical answers and the content of students' open answers regarding the module, we examined how the revised introduction affected students' perceptions of the usefulness of the module.

Results: Medical students' feedback in the years 1 (n = 81), 2 (n = 99) and 3 (n = 95) showed that the students found the module in the second and third years significantly more useful than in the first year. These results support earlier findings that clearly stated clinical relevance motivates medical students.

Conclusions: When introducing multidisciplinary subjects to medical students, it is important to think through the clinical relevance of the topic and how it is introduced to medical students.

Background

Teamwork skills

Teamwork skills are important for today's medical students. They are essential for good patient care (West et al. 2002; Burke et al. 2004; Baker et al. 2005; Wright et al. 2009), and hence important learning goals in medical curricula (General Medical Council 2003). In order to learn and work effectively in a group or team, medical students might therefore benefit from teaching focused on teamwork skills. Teaching teamwork skills to medical students may be challenging, as they are often mainly interested in topics directly applicable to their future profession (Lonka & Lindblom-Ylänne 1996). Consequently, they may lack motivation to learn topics that are not self-evidently at the core of medicine. Teachers of teamwork skills and other multidisciplinary topics should therefore pay attention to motivating medical students to learn these topics.

Many medical schools worldwide have adopted problem-based learning (PBL) and other interactive small group teaching methods. Studying with PBL is expected to develop students’ teamwork skills (Wood 2003; Hmelo-Silver 2004; Koh 2008). Some elements of teamwork may, however, be difficult for students even if they are familiar with PBL. Students in PBL-tutorial sessions have been found to spend relatively little time on inquiring about each other's reasoning and on asking each other to elaborate on their ideas. Students also rarely deal with conflicting information or differing interpretations (Visschers-Pleijers et al. 2006; Yew & Schmidt 2007). In addition, active listening has often been an overlooked skill in PBL-tutorial sessions (Remedios 2008). Such elements of teamwork could be valuable in enhancing teamwork in PBL-tutorial sessions.

Table

Practice points

Teamwork skills are important for medical students in PBL-tutorial sessions and in health-care teams. Team members’ ability to work and learn effectively together depends a great deal on the quality of their verbal communication. Medical students’ motivation to learn teamwork skills increases if they concretely understand why the topic is clinically relevant and how they can make use of it in the future as physicians. Teachers of teamwork skills and other multidisciplinary topics should assist medical students to appreciate the clinical relevance of these topics. A model for a training session aimed at improving medical students’ verbal communication is presented.

Similar challenges of communication are found in the workplace, where team members may have difficulties in understanding each other's points of view and lack skills to deal with conflicting ideas constructively (Isaacs 1999; Senge 2006). These challenges are also common in health-care teams (Burke et al. 2004), especially between team members from different disciplines (Donchin et al. 1995; Sexton et al. 2000; Lingard et al. 2005). Therefore, improving teamwork skills in medical education is important (Baker et al. 2005; Wright et al. 2009).

In medicine, teamwork skills have usually been taught through various forms of simulations based on real world health-care scenarios (Gaba 2000; Shapiro et al. 2004). Simulations have been found to be useful in improving the quality of teamwork (Shapiro et al. 2004) and patient safety (Gaba 2000). In view of communicational challenges both at PBL-tutorial sessions and at workplace, it might prove useful to teach effective verbal communication at an early stage of studies. Such an approach might improve PBL-tutorial sessions, and complemented later on with simulation training, prepare students for effective communication in health-care teams. Medical students might not, however, perceive such teamwork skills in the beginning of their studies as relevant. Students’ motivation to learn those skills needs, therefore, to be carefully addressed.

Student motivation

In general, students’ motivation to learn may stem from their inherent interest in a topic (intrinsic motivation) or from external rewards, prods or pressure (extrinsic motivation) (Ryan & Deci 2000). As for teamwork skills, most medical students may not be inherently interested in them, and we, therefore, need to consider how these skills can appear rewarding to them.

Furthermore, motivation is connected to goals (Pintrich 2002). In order to become motivated, medical students need to perceive their present activity as valuable toward achieving the goal of becoming a physician. If students appreciate the utility value of a topic, they are more likely to be interested in it, even if the topic had not initially appealed to them (Husman et al. 2004; Simons et al. 2004). Students’ interest is further strengthened if they recognize exciting challenges and promising opportunities in what they are learning (Hidi 2006).

Problems may, however, arise even when students perceive the topic to be of high utility value if it is taught in a way which does not make the usefulness of the content clear to them (Creten et al. 2001). Therefore, it is important to pay attention to how the utility value of a topic is pointed out. When seeking to clarify the utility value of a topic to students, the similarities between present and future tasks should be pointed out, as the utility value of the present learning task is higher when it is seen as requiring the same skills as future professional tasks (Simons et al. 2004). Students’ perceptions of the usefulness of a topic are an indicator of its utility value (Eccles 1995; Husman et al. 2004).

In this study, we describe how we teach teamwork skills to first-year medical students and procedures taken to motivate them to learn those skills. The aim was to find out how to motivate medical students to learn teamwork skills, focusing on verbal communication. We examine how students’ perceptions of the learning module changed after we had revised the teamwork skills module (TSM) as a reaction to students’ feedback.

Methods

Participants

The participants in the study were three consecutive classes of first-year medical students (N = 342) at the University of Helsinki. The first class began their studies in 2006, the second in 2007, and the third in 2008. Each year, all first-year students were divided into four groups for a 2-h session on teamwork skills. There were thus 12 groups of 24–30 medical students, altogether.

Setting

The participants were going through 2-year preclinical studies in a curriculum based on PBL. TSM took place during the first semester, simultaneously with a Cell Biology and Basic Tissues course, which is the third course in the whole curriculum. The TSM was part of a Growing to Be a Physician program (GBP), which, during the first semester, included a variety of issues, such as an introduction to PBL, medical professionalism, communication skills, scientific thinking and medical ethics. The GBP program forms a stream of courses from the first year to the final, sixth year. The TSM was held each year in four parallel sessions with each student participating in one session. After the first year, the module was improved based on the experiences and students’ feedback. The third-year sessions followed exactly the same plan as the second-year sessions (Table 1). The students’ performance was not evaluated or graded, but attendance was compulsory. In the following, we describe how the module was conducted each year and how it was improved after the first year.

Table 1.  Structure of the teamwork skills module

Introduction

Short lecture: Communication in a team. Forms of conversation (discussion, debate, dialogue (emphasized in the first year)) and elements of conversation (attitude toward others, listening skills, question styles, finding key points in communication (emphasized in the second and third years)).

Exercise 1 (Pairs). Story. Pairs create a story together, adding just one word per turn.

Aim: To understand how words represent individual thought processes which may be difficult for the other to understand.

Exercise 2 (Pairs). Listen and repeat. A student tells the his/her partner why he/she wants to become a physician. The partner listens and repeats word for word what the speaker has said.

Aim: To understand that active listening requires effort and concentration.

Exercise 3 (Pairs). Listen and paraphrase. A student tells his/her partner what he/she is expecting from the medical studies. The partner listens and paraphrases what the speaker has said.

Aim: To understand the meaning of effective listening and the role of interpretation in understanding each other.

Short lecture: Elements of effective verbal communication. The role of mutual respect, equal participation, comments that focus on the topic/task, active listening, keywords and sentences, asking questions, and handling conflicts about knowledge in gaining deeper understanding of each other and the topic.

Exercise 4 (Groups of 4). Recoqnizing keywords and sentences. A student tells a group his/her ideas about the major challenges in medicine. The rest of the group listens and writes down key words and sentences from the speech. After a while the group compares the keywords and sentences they have chosen. For example: It is important to guarantee patient safety. Possible keywords: guarantee patient safety

Aim: To learn how to recognize key points in verbal communication which need more clarification.

Short lecture: Asking questions. The role of question styles (open, closed, critical, verification) in gaining deeper understanding of each other and the topic or checking understanding. For example: What does guaranteeing patient safety mean? (Open question).

Exercise 5 (Groups of 4). Identifying keywords/sentences and form a question about it. A student tells his/her understanding about the idea and purpose of cell division. His/her partner listens and selects keywords/sentences and forms questions that aim to deepen the understanding of the other's ideas. After a couple of questions, they change roles. The rest of the group observes and evaluates how well the questions seemed to deepen their understanding of the speakers’ thoughts.

Aim: To learn to identify key points in communication and form relevant questions which help to deepen understanding of these points.

Exercise 6 (Groups of 4). Improving PBL-tutorial sessions. The group discusses how they can improve their PBL-tutorial sessions with these elements of effective verbal communication.

Aim: To reflect on what is learned and how to apply it in practice.

Teamwork skills module

The TSM was a 2-h intensive session consisting of an introduction to the topic, short lectures, and interactive exercises for pairs of students, and small groups (for an outline of the session, see Table 1). The aim of the session was to develop students’ verbal communication so that they could work and learn more effectively in a team. The short lectures dealt with (1) differing styles of conversation, such as discussion, debate, and dialogue, and (2) various elements of conversation, such as attitude toward others, listening skills, questioning styles, and finding key points in communication, and their roles in effective teamwork. The exercises focused on active listening, identification of key points in verbal communication, and techniques for asking questions in order to better understand the topic at hand and each others’ points of view.

Similar elements concerning the communication in a team are found in training programs aimed at improving teamwork in healthcare (Morey 2002; Grogan et al. 2004). In our module, we concentrated on elements of teamwork that are also important for communication in PBL-tutorial sessions. The idea was that after the TSM, the students would be more aware of these skills and could consciously practice them in PBL-tutorial sessions. Later in the program, these skills could be built on and further developed through clinical practice and simulation training.

In the first year, teamwork skills were introduced with an emphasis on the students’ present challenges. The topic was approached by discussing typical causes for poor teamwork in PBL-tutorial sessions. Verbal communication was presented as a crucial teamwork skill in preventing these problems and in making PBL-tutorial sessions successful. Communication in a team was linked to students’ future work by noting that modern medical experts often work in health-care teams.

The feedback from the first year's TSM indicated that the majority of the students did not perceive it as very useful. As we, however, still considered the topic and the exercises to be valuable for medical students, we concluded that we had failed to demonstrate the relevance to the students clearly enough.

Improving TSM

For the second and third years, we sought to make the module more motivating. The only major change we made, however, was to the introduction to the topic. This time, we carefully explained why teamwork skills are important for physicians. Thereby, we sought to emphasize the utility value of teamwork skills for medical students. The topic was approached by first discussing the common competencies required in both PBL-tutorial sessions and health-care teams. After this, we showed findings from recent studies, where effective communication in health-care teams has been found crucial for preventing medical errors (Alvarez & Coiera 2006; Singh et al. 2006). We further explained that in PBL-tutorial sessions, students not only acquire medical knowledge, but also have a chance to practice effective verbal communication – a highly relevant skill in many clinical situations.

Apart from the introduction, the outline of the sessions, theoretical background and exercises all remained the same. Minor changes in emphasis were made to how communication in a team was dealt with in the short lectures. In the first year, the emphasis was on different forms of conversation and their characteristics, whereas in the latter years, we focused more on the elements of conversation.

Materials and procedures

The data were collected in three parts, using a web-based feedback system, in the autumns of 2006, 2007 and 2008 after each year's GBP. The questionnaire contained questions pertaining to the whole GBP course of the first year. It also indicated the students’ gender. One question focused specifically on TSM. Students were asked to respond to the statement ‘Teamwork skills module was useful’ using a five-point Likert rating (1 disagree completely, 2 disagree, 3 neutral, 4 agree, and 5 agree completely). In this scale, ‘1’ is the negative end and ‘5’ the positive end. The means of students’ answers were computed for each year and compared with an independent samples T-test.

The questionnaire also included two open questions: ‘What helped you learn, or worked well, in this course?’; ‘How would you develop this course?’ Out of these answers, we examined those referring to TSM with qualitative content analysis. The comments referring to TSM were categorized as either positive or negative.

Results

The response rate in the year 2006 was 81/105 (77.1%) students (women 53, men 28), 99/117 (84.6%) students (women 63, men 36) in 2007 and 95/120 (79.2%) (women 54, men 41) students in 2008. The students perceived the TSM as less useful in the first year (M = 2.46, SD = 1.27) than they did in the second (M = 3.07, SD = 1.02) and third years (M = 2.99, SD = 1.07) (Figure 1). The difference was significant between the first and second year (t (173) = 3.52, p = 0.001), and between the first and third year (t (169) = 2.96, p = 0.004), but nonsignificant between the second and the third year. Effect sizes (Cohen's d) were calculated for the difference in the students’ feedback between the first and second year (d = 0.53), and between the first and third year (d = 0.45). In terms of the students’ gender, there were no significant differences between the years.

Figure 1. Students’ perceptions of the usefulness of the teamwork skills module in the years 1 (n = 81), 2 (n = 99), and 3 (n = 95); percentages of the students’ answers to the statement ‘Teamwork skills module was useful’.

Of the consecutive 3 years studied, there were altogether 130 open feedback comments by the students, of which 15 referred to TSM. In the second and third years, there were slightly more positive comments than in the first year. In the first year, out of four comments there were two positive and two negative comments referring to TSM. In the second year, there were seven comments altogether, of which four were positive and three were negative. In the third year, out of four comments, three were positive and one was negative. Each year, the students who commented on TSM positively or negatively also gave numerical feedback accordingly on the positive or negative end of the scale (see the examples below). The students’ main concern in the first year seemed to be that the module was not interesting, whereas in the second year, more students felt that they had concretely benefited from the module.

Student 1. (First year) gave rating 1 (disagree completely) and commented: ‘TSM should be developed so that it would be more interesting.’

Student 2. (Second year) gave rating 4 (agree) and commented: ‘In TSM, I concretely realized the areas of communication that I need to improve.’

Even though there were more positive comments about the second year's sessions, one negative comment in the second year illustrates the challenge of teaching multidisciplinary topics to medical students.

Student 3. (second year) gave rating 2 (disagree) and commented: ‘TSM didn’t go down well with me at all, (you have a tough job to please a typical medical student who only wants hard data and shuns ‘light courses’).’

In the third year, there was one positive comment which included concrete ideas for improving the module.

Student 4. (Third year) gave rating 5 (agree completely) and commented: ‘TSM was useful. Our PBL-tutorial group changed like magic to being more fluent, spunkier and more creative. Unfortunately, the effect was only temporary. I was wondering if TSM could be merged with some PBL-tutorial sessions, that is, a teamwork skills teacher would come to the PBL-tutorial sessions to observe the communication and give advice in difficult situations.’

Discussion

We developed a teamwork skills module for first-year medical students to improve their verbal communication in a team. Medical students need such skills for learning in PBL-tutorial sessions and later when they work in health-care teams. In these contexts, verbal communication aiming at understanding other team members’ points of view, the topic and the situation at hand is essential (Peterson 1997; Burke et al. 2004).

However, the feedback from our first year's TSM showed that the medical students did not find it useful. In the first year, teamwork skills were introduced to the students as crucial for improving teamwork in PBL-tutorial sessions. The meaning of teamwork skills for physicians was referred to only by explaining that teamwork is common in modern medicine. Concentrating on challenges in PBL-tutorial sessions without a concrete connection to their future profession was perhaps too commonplace or professionally unchallenging for medical students. Their primary interest is to become physicians, and topics whose contribution to attaining this goal is not directly apparent may seem useless.

Therefore, we revised the introduction to teamwork skills and sought to point out the meaning of these skills for the students’ future profession more clearly. Otherwise, we left the module virtually unchanged. In the second and the third years, teamwork skills were introduced as crucial for preventing medical errors. After the 3 years, we compared the students’ feedback and examined how the revised introduction had affected the students’ perceptions of the usefulness of the module.

The results showed that the medical students found TSM in the second and third years significantly more useful than in the first year. The difference between the first and second year and between the first and third year showed a medium size effect (Cohen 1988). Pointing out the clinical relevance of the topic most likely increased the students’ motivation to learn these skills. These results are in line with earlier findings that emphasize the importance of clinical relevance for medical students’ motivation (Rudland & Rennie 2003). Considering the possibility of preventing medical errors in the future may have affected the students’ evaluations of the utility value of these skills. The results also highlight the importance of how clinical relevance is pointed out. Preventing medical errors with teamwork skills may have functioned as a surprising and emotion evoking challenge for the students, which is important in the early stage of the interest development with a new topic (Hidi 2006). These aspects probably explain the significant increase in the perceived usefulness of TSM.

There are certain methodological limitations to this study. First, there was only one statement in the questionnaire about the students’ perceptions of the usefulness of TSM. More questions concerning the students’ perceptions would have increased the reliability of the measurement. It might, for example, have been useful to further specify for what purpose the students thought the module would or would not be useful. However, the students found the second and third year's sessions significantly more useful, which indicates that the revised introduction positively affected their perceptions.

The size of the sample and the homogenous groups made it possible to examine the effect of the revised introduction. The fact that each year's cohort was divided into four groups decreases the chance that situational factors could have compromised the reliability. The setting was highly comparable between the 3 years, as the teacher, group sizes, and the time of the semester were the same. The classes were homogenous in terms of gender and all the three classes had passed a similar entrance examination to be accepted to medical school. Conclusions made from the statistical analysis were also supported by a qualitative content analysis of the students’ open feedback.

Second, we asked the students to give their opinion soon after the module. A more reliable understanding of the students’ perceptions of the usefulness of TSM would call for a follow-up inquiry after they had been exposed to more situations where teamwork skills are needed. Finally, the majority of the students (88.5%) did not mention TSM in their open feedback. Therefore, we do not know how the students whose numerical feedback was close to the mean would have commented on the sessions.

Some contextual factors may also be important when interpreting the results of the study. TSM took place simultaneously with the Cell Biology and Basic Tissues course. This may have affected students’ motivation, as teamwork skills may seem irrelevant to the study of basic medicine. The TSM teacher had earlier experience in teaching these skills to physicians. The biggest challenge for the teacher was to shift from the context of teaching physicians to teaching first-year medical students, for whom it may be difficult to see the clinical relevance of the topic. According to the teacher's self-evaluation, succeeding in pointing out the clinical relevance of teamwork skills was a significant improvement between the first year and the two following years.

Conclusions

Teaching multidisciplinary topics to medical students may require paying extra attention to motivating the students. It seems important to analyse the clinical relevance of the topic and plan how it is introduced to medical students. The results of this study support the notion that the clinical relevance of a topic is crucial for medical students’ motivation even in the early stage of their studies (Lam et al. 2002). It also seems that clinical relevance has to be stated in a way which helps students to concretely understand why the topic is important for them and how they can make use of it. Further studies are needed to find out if such an increased motivation leads to enhanced teamwork after the session. The findings of this study can be used in planning how to introduce multidisciplinary topics to medical students. The piloted model of instruction and exercises provide examples when designing teaching of teamwork skills in schools of medicine.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Matti Aarnio

MATTI AARNIO is a teacher educator and researcher for the Research and Development Unit for Medical Education at the University of Helsinki.

Juha Nieminen

JUHA NIEMINEN is a study psychologist and a teacher educator for the Centre for Research and Development of Higher Education and for the Research and Development Unit for Medical Education at the University of Helsinki.

Eeva Pyörälä

EEVA PYÖRÄLÄ is a senior lecturer of university pedagogy for the Research and Development Unit for Medical Education at the University of Helsinki.

Sari Lindblom-Ylänne

SARI LINDBLOM-YLÄNNE is a professor of higher education and director of the Centre for Research and Development of Higher Education at the University of Helsinki.