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How to work with reflecting teams

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									Niels Kristian Kjaer, GP, MHPE, senior lecturer, Vester Sottrup, Soenderborg, Denmark: nk@telemed.dk Charlotte Tulinius, MD, Ph.D., MHPE, senior researcher, Central Research Unit of General Practice, Copenhagen, Denmark: c.tulinius@dadlnet.dk

How to work with reflecting teams
What is a reflecting team? A reflective team consists of 7-10 professionals with practical experiences within the topic. The set-up is to make these practitioners reflect over their knowledge and experiences. The environmental setting? A reassuring, comfortable environment is essential. Without a secure setting the intentions will not be met in this kind of training. What are the roles? The participants of the team are given a role each. The roles shift from session to session The roles are:  a case-holder  an interviewer  a reflecting group of three persons  a timekeeper  one or more process observer. If only 6 persons are present the timer keeper will also function as process observer. What is the focus of the team? The focus of a reflecting team is the “case-holder” and the “interviewer”. They are assisted by a reflecting group of three persons. How does the session run? The session is led by the “time-keeper” who observes the process. The point of departure in the case is a so called “critical incident”: A positive or negative event which made an impression on the case-holder. Before the session the case-holder has found such an experience and written it down. In the session he tells the interviewer about his experience. The interviewer can pose a few questions to stimulate the reflection of the case-holder. The reflective group listens and comments on the interview, when the time-keeper allows the group. But it shall not be an intervention. The reflecting group does not address the two in focus, but they discuss their thoughts generated during the interview they just heard. The interviewer and the case-holder listen to this discussion in the reflecting group and get ideas for the further interview. There is a structured time table but the time keeper is allowed to extend or shorten down the interval if suitable. What is a critical incidence? The so called “critical incident” is a case or situation, which surprised you in a positive or negative way. A situation different from the routine cases, that in some way made you think or

even change perception. Beginning a discussion with such an event opens for the possibility to uncover your own and your colleagues’ practical knowledge and non-verbalised strategies in order to strengthen them. In these session we will look at events, related to tutoring. It is not mandatory to bring your own cases but it is advisable, because it gives you the chance to discuss difficult matters with competent colleagues. It is important to remember, that the sessions are NOT supervision or therapeutic set-ups. The interviewer is not expected to go into in-depth analysis of the case-holder’s story, but has instead to stimulate the reflection of the case-holder. In order to make him understand and realise the “problem(s)” in the case, or put in another way, help clarifying “what this is a case about”. During a session it is very common, that the problem is redefined several times, indicating a developed deeper understanding by the case-holder.

Time table of a session          The case holder presents his case 5-10 minutes. The interviewer asks questions/conducts a dialog in order to stimulate reflection and define “what is this a case of?” 5-7 minutes. The reflecting group discusses, what they have heard, and what thoughts and considerations it has generated. 3-5 minutes. The case-holder and the interviewer continue their discussion/dialog , using ideas gained from listening to the reflection group. 3-5 minutes. The reflection group reflects again 3 minutes The case-holder and the interviewer end their dialog. 3 minutes The interviewer gives his ending remarks. 1 minute The case-holder gives his conclusions and impressions from the session. The time keeper / process observer comment(s) on the process but NOT on the content, which is finished by the case-holder’s ending remarks. The rest of the team is allowed to comment but again ONLY on the process. If relevant the trainer can add feedback concerning the session process The case-holder is asked if he has anything to add. (He ends the session) Everybody rise and change position/change chairs or walk to another room. It is necessary with some physical activity to underline, that the sessions is over.

 

The trainer’s instruction
This instruction contains:  An instruction guide in the use of reflective teams  A hand-out to the participants, already send to them in advance. It is important, that the trainer knows the information given to the participants as well An instruction guide in training reflective teams. What is a reflecting team? A reflective team consists of 7-10 professionals with practical experiences within the topic. The set-up is to make these practitioners reflect over their knowledge and reflection-in-action as described in the hand-out. A reassuring, comfortable environment is essential, the Trainer has to show (and feel) respect and understanding for the working conditions for the GP’s. Without a secure setting the intentions will not be met in this kind of training.

The environmental setting?

How much instruction is needed? Proper instruction as it is described in this paper is essential and has to be repeated in the first 2-3 sessions. Prior knowledge among the participants? Ask if any of the participants have had prior experiences with working in reflecting groups. If so let them tell shortly about the experiences if possibly relate it to the actual session. Explain the purpose and defining the rolls for the tutortrainee’s. The roles are:

What are the roles?     

a case-holder an interviewer a reflecting group of three persons a timekeeper one or more process observers. If only 6 persons are present the timer keeper will also function as process observer. Explain that the focus of a reflecting team is the “caseholder” and the “interviewer”. They are assisted by a reflecting group of three persons.

What is the focus of the team?

How does the session run?

The session is led by the “time-keeper” who observes the process. The point of departure is “a case” it is a so called “critical incident”: A positive or negative event which made an impression and/or changed conception for the caseholder. Before the session the case-holder has found such an experience and written it down.

In the session he tells the interviewer about his experience. The interviewer can pose a few questions to stimulate the reflection of the case-holder. The reflective group listens and comments on the interview, when the time-keeper allows the group. But it shall not be an intervention. The reflecting group does not address the two in focus, but they discuss their thoughts generated during the interview they just heard. The interviewer and the case-holder listen to this discussion in the reflecting group and get ideas for the further interview. There is a structured time table but the time keeper is allowed to extend or shorten down the interval if suitable. Important in the instruction Explain to the team, that the sessions are NOT supervision or therapeutic set-ups. The interviewer is not expected to go into in-depth analysis of the case-holder’s story, but has instead to stimulate the reflection of the case-holder. In order to make him understand and realise the “problem(s)” in the case, or put in another way, help clarifying “what this is a case about”. During a session it is very common, the problems is redefine several times, indicating a developed deeper understanding by the case-holder. Ask after comment or questions. Show the participants the timetable The role of the trainer? The role of the instructor is to make the start-introduction, and to answer questions from the group concerning the process and set-up. If relevant he can give feedback concerning group process after the observers have commented on the process. It is not expected, that he shall intervene during the session or comment on the content of the discussion - except in situations where a participant is at the risk of getting harmed.

Cautions: The trainer’s intervention is appropriate   IF the interviewer starts in-depth analysing the case-holder, who shows verbal or nonverbal signs of discomfort. IF any member of the team keeps breaking the rules or the set up, in a way that disturbs the reflection process. Some space for “rule breaking” or “rule redefinition” should be allowed. It is most suitable if the team-members themselves detect “inappropriate group process” and strengthen the set up.

Time table of a session          The case holder presents his case 5-10 minutes. The interviewer asks questions/conducts a dialog in order to stimulate reflection and define “what is this a case of?” 5-7 minutes. The reflecting group discusses, what they have heard, and what thoughts and considerations it has generated. 3-5 minutes. The case-holder and the interviewer continue their discussion/dialog , using ideas gained from listening to the reflection group. 3-5 minutes. The reflection group reflects again 3 minutes The case-holder and the interviewer end their dialog. 3 minutes The interviewer gives his ending remarks. 1 minute The case-holder gives his conclusions and impressions from the session. The time keeper / process observer comment(s) on the process but NOT on the content, which is finished by the case-holder’s ending remarks. The rest of the team is allowed to comment but again ONLY on the process. If relevant the trainer can add feedback concerning the session process The case-holder is asked if he has anything to add. (He ends the session) Everybody rise and change position/change chairs or walk to another room. It is necessary with some physical activity to underline, that the sessions is over.

 

Instruction for the participants
This instruction consists of  An advanced organiser  An instruction in how to work in reflecting teams  The programme for the training sessions

Advanced organiser In four evenings we will take you through a training course for tutors in general practice. The content of the course is based on interviews with experienced and less experienced tutors. The course will help you to understand different ways of learning, what happens when doctors develop clinical competence, how to stimulate and facilitate this development, how to deal with the sometimes complicated trainee-tutor relationship and how to benefit yourself from being a tutor. You will not learn how to lecture nor to teach textbook knowledge - but how to give your trainee the space and surroundings necessary to professional growth. One of the tools we will introduce to you is working in reflecting teams. The set-up is based on Donald Schön’s theories of the reflective practitioners. According to his thoughts the scientific knowledge can only explain a minor part of the problems, that patients present to us. The problems of the patients are often different from the descriptions in the medical books, and the practitioners have to rely on their own and colleagues’ experiences, developing the practical knowledge. Filling the gab between theory and practice is one of practitioners most prominent competencies. But often we as practitioners are not aware of these skills. If we as tutors shall transfer this know-how to the trainees, we must verbalise the know-how and find ways to let the same qualities grow within the trainee’s heads. The aim of the method we have chosen is to provide protected time for deeper consideration and reflection together with colleagues with similar experiences. Along with this we will discuss new thoughts about learning and professional development with you. When young doctors come to our clinics, it happens that they are less independent than we would find suitable. Our function is to help the trainees to develop not only factual knowledge but also more self-esteem and guide them towards a self directed way of learning, preparing them for life long learning. In other words, in our tutoring we must meet the trainees where they are, and during the stay with us guide them into a more independent professional style. The design of this course will mirror the way towards self directed learning. In the start of the course we as educators will control the sessions but gradually we will let you set the agenda. This will give you the impression of a shift from teacher’s to learner’s control.


								
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