Virtually present: The perceived impact of remote facilitation on small group learning

Abstract

Background: The engagement of facilitators located remotely for small group learning has received little research attention. However, this approach could increase the pool of experts for small group learning, thus addressing challenges to sustainability faced by in-person models of small group facilitation.

Aim: The objective of this study was to describe the experiences and perceptions of students regarding the use of remote facilitation for small group learning in a health education setting.

Methods: This qualitative study involved three focus groups (n = 16) composed of students in the advanced neuromusculoskeletal teaching unit in the University of Toronto, Department of Physical Therapy. Focus groups were audio-taped and transcribed verbatim, and data were analyzed thematically.

Results: Three main influences emerged related to the experiences of students regarding the use of remote facilitation for small group learning in a health education setting: technology (including audio and visual), facilitator (including quality of facilitation and facilitator expertise), and group dynamics (including ground rules, roles and responsibilities, and learning style). Each of these influences acted independently and interdependently to shape participants’ perceptions.

Conclusion: This study prompts a widening of the concept of distance learning to also include distance teaching, which may have wide applicability to health profession programs.

Introduction

Small group learning has become an effective and mainstream teaching approach in health professional student education (Lake 2001; Holland et al. 2008). Small group facilitators are often recruited from the clinical community as ‘experts’ to guide a structured face-to-face learning experience. However, changing clinical demands facing these experts have begun to compromise their availability and challenge the sustainability of small group learning (Ruiz et al. 2006).

Distance learning is a form of e-learning described as the use of information technology to deliver instruction to learners remote from a central site (Ruiz et al. 2006; Cook et al. 2010). Videoconferencing is a distance learning strategy in which content is delivered synchronously and direct communication occurs among facilitator and learners (Lau & Bates 2004; Ruiz et al. 2006). To this end, videoconferencing has proven to be a useful mechanism for small group learning whereby learners are located remotely and the facilitator is at a central, often academic, site. This approach has been particularly meaningful for addressing the educational needs of learners in under-serviced areas (Ahn et al. 2007; Holland et al. 2008). For example, Allen et al. (2003) assessed the use of videoconferencing for post-graduate education using small group learning with physicians in Nova Scotia, Canada. They found that videoconferencing had the potential to bring the benefits of small group practice-based learning to health professionals distributed throughout the region, provided challenges related to use and cost of the communication technology were addressed. O’Rourke (2007) then assessed the use of this same curriculum in Scotland with similar results. Hadley and Mars (2008) found satisfaction among physicians using videoconferencing in South Africa to enhance knowledge about pediatric surgery. In another example, Olsen et al. (cited in Augestad & Lindsetmo 2009) used small group learning through videoconference to reach dentists in remote parts of Norway.

In each of these examples, the learners have participated remotely in the small group learning while facilitators have been centrally located. The one exception in the literature is a study by Crump et al. (1998) who assessed a hybrid model of small group learning. In this approach, medical students first participated in a face-to-face small group session with a facilitator, followed by a second session through videoconferencing, and finally a third session via audio-only teleconference. Videoconferencing was found to be as acceptable to the students as other methods of small group learning.

Given that videoconferencing may be used as an alternate strategy for small group facilitation, its role in promoting and sustaining small group learning in health professions education warrants further examination. In particular, little is known about the use of videoconference to enable experts to remotely facilitate small group learning without any prior face-to-face engagement with learners. The shift of health professional curricula toward more collaborative approaches to teaching and learning will require a larger number of skilled small group facilitators. Engaging facilitators remotely could increase the potential pool of experts for small group learning, thus addressing the issue of sustainability faced by current models.

To date, the use of remote facilitators for small group learning lacks empirical evidence to inform faculty interested in engaging in this approach. Therefore, we undertook a study to explore remote facilitation within a curriculum that had previously used an in-person facilitation model for small group learning. The objective of this study was to describe the experiences and perceptions of students regarding the use of remote facilitation for small group learning in a health education setting.

Table

Practice points

Skype™ provides a strategy for overcoming the main barriers to e-learning through videoconferencing in terms of cost and need for specialized equipment. There is an interdependence of the influences on students’ perceptions regarding remote facilitation, therefore, there is a need to consider all influences comprehensively. In addition to distance learning, there are also potential roles for distance teaching.

Methods

Study design and setting

This qualitative study used focus groups to explore students’ perceptions of the benefits and challenges of remote small group facilitation. This inquiry was developed in response to the challenge of securing an adequate number of expert facilitators for the case-based small group learning component of the advanced neuromusculoskeletal teaching unit in the University of Toronto, Department of Physical Therapy. The unit aimed to develop clinical reasoning skills among senior students and, therefore, required facilitators who were physical therapists with clinical expertise. Because of the increasing difficulty securing physical therapists who could commit to facilitating eight weekly session onsite, a new model was introduced in 2008 whereby the student group continued to meet onsite, but was led by a facilitator who participated remotely using either Adobe ConnectTM or SkypeTM for audio and visual connections.

During this remote facilitation, the students were located around a long rectangle table in a small group room at the university. A computer located at one end of the table was connected to the Internet, a webcam, speakers, and a projector that displayed a larger version of the monitor's image on a screen behind the computer. Each facilitator was located offsite in a quiet office (often at her/his clinic) in front of a computer with a webcam, microphone, and speakers. Students in the teaching unit were randomly assigned to participate in remotely-facilitated or face-to-face small group session.

Participants

Student volunteers were recruited from the 2008 and 2009 classes that had experienced the remote facilitation model. Eligible participants included a convenience sample of all students in the 2008 class who had experienced remote or face-to-face facilitation models, and a purposive sample of the students in the 2009 class who had experienced the remote facilitation model. These students received an invitation to participate and a study information package. Further information was provided to potential participants by a member on the research team who did not have an evaluative role with the students.

Data collection and analysis

Data were collected using focus groups informed by a semi-structured interview guide to explore participants’ perspectives about remote facilitation and small group learning. The focus groups were audio-taped and transcribed verbatim. Identifying information was removed from the transcripts and they were reviewed for accuracy by the focus group facilitators. Demographic data of the participants (i.e., birth date, sex, and age) were collected using a short survey. This study was approved by the Research Ethics Board at the University of Toronto.

Data were analyzed by first reading each of the focus group transcripts several times to develop familiarity with the data. A coding framework was developed based on the research question and ideas emerging inductively in the transcripts. Two research team members coded each transcript independently. The team then convened a series of meeting to discuss these descriptive results and to organize them conceptually in terms of themes (or “influences”, as will be seen in the subsequent sections).

Results

Participant characteristics

The study included a total of 16 participants in three focus groups. Two focus groups were convened in 2008 with five participants in a focus group that included individuals whose small groups had used a remote facilitation model for small group learning and seven participants in a focus group of individuals whose small group facilitator was located on-site. The third focus group was convened in 2009 and included four participants who had used a remote facilitation model for small group learning. All participants were second-year students in a two-year Master's-level entry to practice physical therapy program in Canada. Ages ranged from 25 to 28 years. Two of the participants were male and 14 were female. All participants had at least one previous Bachelor degree.

Students’ perspectives regarding remote facilitation

Three main influences emerged from the data that related to the experiences and perceptions of students regarding the use of remote facilitation for small group learning in a health education setting: technology, facilitator, and group dynamics. Figure 1 illustrates how each of these influences acts independently (see unidirectional arrows) and interdependently (see bidirectional arrows) to shape the students’ perceptions of remote facilitation in the context of small group learning. In this section, we introduce these three categories of ‘influence’ and their subcomponents, followed by a description of the ways in which they act interdependently to shape students’ perceptions of remote facilitation.

Figure 1. Independent and interdependent influences on student's perceptions regarding remote facilitation.

Influence 1. Technology

A central component of remote facilitation is the technology required to enable communication between students and their facilitators in other locations. Students identified technology itself as one of the three main influences on their experiences of remote facilitation with emphasis on (i) audio and (ii) visual.

1. Audio.

The quality of audio connection impacted how well the group was able to interact. Time delays in audio transmission compromised conversation and limited the ability of people to talk at the same time and still be understood. Poor audio transmission forced students and facilitators to repeat themselves. As one participant explained:

I remember I had a few questions at some points and I would ask them and then, just, I would have to repeat it two or three times. And then I would just be, ‘Okay, forget it, I’ll just look it up myself’ type of thing. So, that was really kind of annoying, the whole delay.

By the second year of the study, audio issues had been addressed, as noted by this participant.

The microphone was on the table so that she could usually hear us pretty well and yeah, I felt that I could look at her, look at her face and see her talking. It almost felt like she was in the room.

1. Visual.

Students were initially located on one side of a long table, which created challenges as noted by this participant:

We also weren’t facing each other. We were all sitting along here looking at the computer screen. So we couldn’t really talk to each other. Because to get the camera to view us all we had to face the camera like this down the line.

This initial set up was later improved by locating students around a smaller table with the video camera at one end, a slight distance from the table. Participants primarily valued the video early in the experience as it allowed them to put a face to the voice of the facilitator. Some student felt the video was important for helping the facilitators recognize which student was speaking. With poor video feeds, some participants were concerned that the facilitators may not have been able to distinguish between students with similar features, as exemplified by this participant:

I did feel like I don’t think they ever knew me from [other student's name]!

Influence 2. Facilitator

The second influence identified by participants was ‘facilitator’ because of the pivotal role that she/he played in shaping perceptions of their small group learning experience. Students’ perceptions of this influence included: (i) the quality of the facilitation, (ii) facilitator expertise, and (iii) the location of the facilitator relative to the group.

1. Quality of facilitation.

The quality of the facilitation was discussed in all focus groups. The facilitator's ability to guide the process, probe thinking, and engage quieter group members contributed to the overall perceived quality of the facilitation. As one participant reported:

She got us thinking outside the box a bit more and thinking more thoroughly about the issues we were talking about. She was really good at that and the real life examples too.

Personality traits like being encouraging, humorous, and open were also seen as contributing to the overall perception of high-quality small group facilitation. Many participants also commented on how the ability of the facilitator to develop relationships with the students influenced their view of facilitation:

You develop a relationship where facilitators are able to facilitate better when they know the students better in the group. I think they can almost sense when they talk too much and when they don’t talk enough, when they know how the group works. So I think it's quite important.

1. Facilitator expertise.

This study involved physiotherapy students participating in small group learning using cases to develop advanced clinical problem solving. Therefore, clinical content expertise that viewed as crucial for the facilitators:

Whenever we had a question or anything, [the facilitators] were very, very knowledge. So they did have information or the answer if we needed it or whatever, so that was useful. If you have a facilitator, they should also have a knowledge base that can be beneficial and they definitely did.

However, there was disagreement among participants regarding the relative value of facilitation skills versus content expertise. Most viewed both abilities as an asset.

Influence 3. Group dynamics

Group dynamics refers to the way in which group members relate to each other and the facilitator in a small group setting. All groups commented on the impact of group dynamics on their small group experience, with emphasis on: (i) ground rules, (ii) roles and responsibilities, and (iii) learning style.

1. Ground rules.

Establishing ground rules or expectations of group members, including both students and facilitators, was perceived as critical by participants in both remote and face-to-face groups. Participants explained how attention to group dynamics paid dividends in terms of group functioning. Others described how group dynamics suffered when they had not been explicit about expectations, as seen in this example regarding punctuality:

It was frustrating because they would come in and they would go, “Oh, sorry I’m late.” And you’d get this big long story, and then it's, “So, what have we done?” Well, I’ll fill you in on the last hour, but … I don’t know, it was more of a hindrance to the group, I guess.

1. Roles and responsibilities.

Many participants described how optimal small group learning requires that individuals fulfill different group roles (e.g., leader, summarizer, and time keeper) as well as group responsibilities (e.g., being on time or providing feedback). Furthermore, participants explained how the significance of these roles and responsibilities was heightened when engaging remote facilitations, but was also harder to establish in the presence of technological problems. As one participant noted:

I think this group could have been a bit more proactive initially, because the equipment was solved rather quickly. It took longer for us as a group to work out our kinks.

1. Learning style.

Several participants believed that an individual's learning styles (e.g., being a hands-on learner and being a visual learner) could influence her/his perceived success with remote versus face-to-face small group facilitation. Although the small group learning approach was not intended to be hands-on (like, e.g., the program's clinical skills laboratories), some students with remote facilitators described feeling disadvantaged, as exemplified by this participant:

I think, too, that it's also just my learning style. I’m very hands-on and visual. I appreciate when people are like, “Oh, well, how do you do this? And, show me,” whereas that's really hard to do with a computer and with SkypeTM.

In the end, however, most students recognized that learning styles are individual requiring a variety of teaching approaches:

… we all have different learning styles at this table. We have 80 or 78 different learning styles in our classroom. Like, you have to have a bit of each for everybody to be catered to and helped.

The interdependence of influences on students’ perceptions

In addition to the independent influences of technology, the facilitator, and group dynamics on participants’ perception of remote facilitation in the context of small group learning, these influences also interacted with each other. For instance, although the nature of the facilitator (including “quality of facilitation” and “facilitator expertise”) shaped students’ perceptions of remote facilitation, the influence of the facilitator was also modified by the other two overarching influences: technology and group dynamics. This interdependence is represented in Figure 1 by the bidirectional arrows. Evidence of interdependence among the influences is presented below.

Technology and facilitator

When examined together, the influences of technology and facilitator had both positive and negative effects on each other. Poor-quality technology had an impact on the ability of the facilitator to communicate with the group, as noted by this participant:

I kind of got the sense that at the beginning they [the facilitators] were a bit frustrated too, with the whole time delay. Especially [when] trying to clarify our questions.

Once many of the technical issues have been resolved, however, one participant explained how the “distance” afforded by the remote facilitator contributed positively to the learning experience:

She was almost a little bit more distant than she might have been face-to-face with the facilitator, which has caused us to have to speak for ourselves a bit more which was good.

With the facilitators being located in their clinics or offices, participants remarked on the benefit of facilitators having immediate access to resources such as research articles or clinical outcome measures that they were able to instantly forward to the group. However, facilitators’ presence in their work settings also had drawbacks, as described by this participant:

I think one of the things that I picked up on is that there are lots of distractions on both ends. On [the facilitator's] end, if somebody walked into the office … they would totally have a conversation and we would be sitting it out …

Finally, participants remarked on how technology enabled the facilitators to be in an entirely different setting (e.g., rural or small town setting), allowing the students to be exposed to novel content and conditions.

Technology and group dynamics

The influences of technology and group dynamics also acted interdependently to impact on the students’ overall perception of small group learning. One participant explained the challenge of teasing apart weak group process from the initial technology challenges:

It may have been sort of intertangled, because the equipment was bad and we got into a bad routine with this and not taking things over. So, it was sort of one of those avalanche things that sort of rolled. Then we got some better equipment and we decided okay, this is going well. And then we sort of threw it together.

Some participants described how challenges with technology caused the group to avoid seeking support from the facilitator until they had evolved their thinking internally. Depending on the individual's perspective, this was viewed as both negative and positive:

… with the remote facilitator, unless we kind of spoke up into the [microphone], they couldn’t always hear us. So, I felt that sometimes when were just discussing amongst ourselves we’d have quieter voices because we were just talking to each other in our small groups. They couldn’t really pick up on all that audio. So, I think they were kind of in the dark about our thought processes. Like, we would tell them our final answer when we got it, but I don’t think they had a clear understanding of how we reached that, like what our thought processes were, just because we’re not thinking out loud very, very loudly. We’re just kind of discussing amongst each other.

… as long as we then compiled our thoughts and spoke them aloud so [the facilitator] could hear them, it worked out okay. Also, I felt that it was better that way because it was almost that we were given a little bit more independence, a little bit more time to work through the cases on our own and problem-solve before we presented what we had come up with to her.

Facilitator and group dynamics

The facilitator's style was seen to influence how group members worked together, and vice versa. Participants described how good facilitators were able to create a safe environment, which resulted in students feeling more open to sharing ideas and learning collaboratively. Conversely, one participant reported how a facilitator's approach served to constrain group dynamics:

[The facilitator] would say a particular person's name, like, ‘[Student's name], what do you think about that?’ And, then she would answer and then [the facilitator] would just ask somebody else, ‘What's your … you know.’ So there was no interaction at that time between the group members.

Some participants expressed that facilitation skills were more important for certain group dynamics-related communication. As one participant noted:

I think facilitation is very important to the dynamic where a group is quiet. I think if you re-ask the question and provoke the thought that came across.

Finally, group dynamics were also seen to influence the facilitator. In one case, a participant explained that her group had ‘strong’ personalities who may have compromised the facilitator's role:

We overpowered her and so we needed someone a little stronger.

Discussion

This is the first study to examine student perceptions of the impact of remote facilitation on small group learning in health professions education. Given that the students in this study were already experienced in small group learning with an onsite facilitator, we expected the primary issues created by the shift to remote facilitation to focus on previously identified technical audio and visual concerns (Allen et al. 2003). As such, we were surprised to discover how the addition of a remote facilitator heightened the importance of attending to the abilities of the facilitator as well as the significance of the group's dynamics. Building on this and other findings, Table 1 outlines practical recommendations emerging from the study that may serve to enhance the use of remote facilitation in the context of small group learning.

Table 1.  Checklist for using remote facilitation

Pay attention to the quality of technology:

□ Ensure that computer system and internet connection is fast enough to avoid audio and video delay

□ Ensure computer screen is large enough so that the image of the facilitators can be clearly viewed by the students

□ Ensure that the camera view is able to capture all of the small group members while also allowing the group to sit comfortably around a table

□ Ensure that speaker and microphones at both locations (remote and local site) are adjustable and at the right volume level to facilitate hearing clearly on both sides

□ Consider using a headset for the facilitator as this can improve the audio for both sides

Pay attention to room set up:

□ Ensure group sitting at a table that is an appropriate size and shape: i.e., small enough to allow students to interact with each other and the facilitator; large enough to allow comfort and working space for the group members. Rectangular or oval shaped tables lend themselves more to this set up compared with square or round tables.

□ Ensure placement of the computer monitor is such that it can be comfortably viewed by all group members; this is often at the head of the table

□ Ensure room is quiet with no external noises to optimize interaction with the facilitator

□ Ensure lighting allows group participants to view the computer screen and is sufficient to allow the camera to pick up their images

Be explicit in expectations of group norms:

□ Rules around how the group communicates with each other needs to be explicit since body language is more difficult to read remotely

□ Be clear about what roles each group member (including the facilitator) will play to assist with group process (e.g., who is the leader, summarizer, recorder)

□ Establish the style of facilitation the facilitator use (e.g., teacher, coach, etc.)

□ Determine how each session will run (e.g., will there be any social time at the beginning of each session? will there be an update on where the group is in terms of work accomplished to date? will there be time protected at the end of each session to debrief the process and accomplishments of that session or provide feedback to individual group members?)

□ Ensure that students sit in the same positions each week to assist the facilitator in getting to know the group members

□ Have a back-up plan should the technology fail

Invest in relationship-building with students over and above the formal educational mandate:

□ Plan to have an additional orientation session with the students and facilitator(s) to allow the group to start getting to know each other and to develop ground rules

□ Encourage some social sharing at the beginning of each session

□ Encourage facilitators and students to maintain their “human side” (e.g., sense of humour)

Be aware that perceptions of what constitutes a positive or negative small group experience is individual and is influenced by many factors:

□ Check in with the group at the beginning of the learning activity and throughout the activity in an attempt to understand what might improve the learning experience

□ Encourage students to take ownership of their small group experience and their learning

Explore learners’ expectations regarding the purpose of the small group learning activity even if it seems obvious (e.g., not hands-on learning, does involve self-directed learning):

□ Be explicit with the group regarding the purpose of the learning activity, including what the negotiables are and are not for the activity

□ Check in with the group throughout the learning period to ensure that learner expectations are still appropriate for the activity and that they are being met

Remote facilitation for small group learning: A model worth exploring

In this era of increasing demand for the time and talent of clinical experts in both the healthcare and educational settings, the onerous human resource requirements of facilitated small group learning present a serious challenge. As educators explore creative ways to engage and sustain the involvement of clinical experts whose time is increasingly scarce, remote facilitation seems to be a model worth exploring.

First, the engagement of facilitators whose only requirement for participation is a computer with audio and visual capabilities as opposed to being physically present opens up a cadre of individuals who would otherwise be excluded from this kind of educational enterprise. This includes talented clinicians who may work in remote or rural environments; however, it also includes experts in the same city but for whom travel time precludes their involvement in small group facilitation.

Second, this model of remote facilitation allows the student group to remain in their academic setting, which has multiple advantages. This form of learning is least disruptive and closely mimics their typical experience of physically coming together to learn collaboratively. This close proximity better enables peer-support within their student group since they are physically together in contrast to other distance learning models where the students are physically alone when they engage in group learning. Furthermore, housing the student groups at the university enabled the faculty responsible for the teaching unit to be immediately available to help manage challenges related to technology as well as broader curricular questions about the material.

Contributions to the literature on distance learning and videoconferencing

Previous studies have largely viewed “e-learning through videoconferencing” as a compelling but largely unfeasible idea. First, the technological requirements described in the literature have been cumbersome and prohibitively expensive prior to the advent of free Internet-based communications such as SkypeTM (Augestad & Lindsetmo 2009). Furthermore, videoconferencing has previously required facilitators to initiate learning from their institutions where particular forms of videoconferencing equipment were housed (Canning 1999; Allen et al. 2003; O’Rourke 2007; Holland et al. 2008). In 2003, Allen et al. reported that e-learning through videoconferencing was well accepted by both learners and facilitators, and led to positive learning outcomes. However, they also acknowledged that the cost of the videoconferencing equipment was a significant barrier for its implementation in other programs. The use of SkypeTM in this study overcomes this barrier, demonstrating its feasibility for small group facilitation and learning without the cost of additional videoconferencing equipment.

In contrast to the majority of distance learning research concerning small group facilitation (Canning 1999; Allen et al. 2003; O’Rourke 2007; Holland et al. 2008), a key innovation in our study was that learners were located at a university base while the group facilitator was connected remotely. As such, our study adds to the new wave of evidence on the role that free and accessible communication technologies can play in reducing the reliance on facilitator-initiated technology from a central institution. In one other study involving remote facilitation, Crump et al. (1998) introduced a hybrid approach in which the group started with face-to-face facilitation followed by videoconferencing with a remote facilitator for the second session and then voice-only remote facilitation for the third session. Crump et al. explained that the face-to-face introduction seemed to support the acceptability of the audio-only third session. This hybrid model of facilitation offers an important innovation, yet requires the facilitator to be on-site for the first session, which prohibits some individuals from being involved. In contrast, facilitators in our study never met students in person. Furthermore, Crump et al. assessed students in three weekly sessions, whereas our study demonstrated the feasibility of remote facilitation over eight weekly learning sessions.

Reports of distance learning are usually based on experts in universities talking with students in remote settings. This study widens the concept of distance learning to also include distance teaching where experts working in remote settings can engage with students located in their home university. Such an approach could be valuable in many health educational programs.

While there are institutions whose mandate includes distance learning for students who choose to engage in a program remotely, this shift toward distance teaching is applicable to all educational programs, including those who may not view themselves as offering distance learning opportunities. Remote facilitation offers a creative way for educators to engage experts beyond their physical base in education roles who otherwise might be inaccessible.

Conclusion

To our knowledge, this is the first study to examine the use of remote facilitation alone as an alternative to face-to-face facilitation in small group learning for health care education. This study explored a novel approach to small group learning taken in response to shrinking local resources. It explores the perceptions of the learners regarding the education delivery mode and adds to the limited body of literature on the subject. Limitations of this study include the homogeneity of the study group and the relatively small sample size. Therefore, while the results illuminate possible considerations for others interested in using remote facilitation for small group learning, the findings may not necessarily reflect the challenges faced by other health professional groups. In addition, two of the focus groups took place in year 1 of the study and the third focus group was conducted in year 2. Although the circumstances surrounding the small group learning in year 2 were different than in year 1, participants’ narratives over the two years tended to reinforce each other as instead of taking up different issues. Therefore, this study serves as a starting point for those who wish to pursue remote facilitation as a way of engaging clinicians otherwise unable to participate in small group learning as a facilitator.

Acknowledgments

We gratefully acknowledge Elizabeth Hanna for her assistance in moderating the focus groups for this study, and the students and facilitators who participated in remotely facilitated small group learning.

Declaration of interest: The authors report no declarations of interest.