Teaching and Learning in Medicine1997, Vol. 9, No. 1,19-24

Copyright 1997 byLawrence Erlbaum Associates, Inc.

Dealing With Dysfunctional Tutorial Groups

Maurice A. Hitchcock and Alex S. AndersonJohn A. Burns School of Medicine

University of Hawaii at ManoaHonolulu, Hawaii, USA

Background: The popularization of problem-based learning has introduced manage-ment of small groups as a critical skill for medical faculty. Some faculty have foundthemselves in dysfunctional groups without the skills necessary to correct the learningclimate.Purpose: This study was conducted to generate strategies faculty can use to deal withdifficult tutorial groups.Methods: Twenty-three experienced tutors were arranged into 5 groups, then rotatedthrough 5 training stations. Each station consisted of 5 students trained to behaveaccording to a dysfunctional scenario. Tutor groups assessed the problem of eachstation group, planned an intervention, and intervened via one of the group's tutors.Results: Assessments of the difficulties in each group varied according to the particu-lar station group scenario being observed. Interventions were tailored to the specificassessments tending from less invasive (i.e., asking questions while the case is beingdiscussed to influence the direction of discussion) to more invasive (e.g., stoppingdiscussion and invoking ground rules) to address the identified problems.Conclusions: We concluded that (1) establishing ground rules is important to thesuccessful development of groups, (2) tutors and groups should deal with conflictdirectly as it arises, and (3) tutors should intervene strategically to foster positivegroup development. A model for strategic intervention is offered.

What do you do when you realize the group ofmedical students you are tutoring in the problem-basedlearning (PBL) curriculm is dysfunctional—that it is"scapegoating a student," or refuses to address learningissues important to the case because "those issues aren'timportant in preparing for Boards." The popularizationof PBL has introduced management of small groups asa critical skill for medical faculty. Social scientists havelong known the impact of the small group on individu-als and have even applied small-group techniques as atherapeutic tool for individuals. Few medical faculty,however, have been trained to manage small-groupdynamics to benefit learning. Some faculty have evenfound themselves in small groups that actually harmindividuals and the learning climate. When such situ-ations occur, they are particularly difficult for studentsand teachers. Faculty must be trained to deal withdysfunctional groups if we are to avoid these outcomes.

Thus, the focus of this article is to better understandthe ways in which faculty (tutors) can intervene indifficult tutorial situations. We began our search forsuch an understanding by reviewing the literature ondysfunctional groups. The search terms, "dysfunc-

tional," "difficult," "problem," "groups," and "PBL,"were used individually and in combinations to searchMedline, ERIC, Psychlit, SocioFile, Business Index,and the University library holdings. Four conclusionswere reached from this search.

The first conclusion was that no research of dysfunc-tional PBL groups has appeared in the literature. Wewere disappointed at not being able to locate any litera-ture explaining either the occurrence or amelioration ofdysfunctional groups in PBL. We had observed severaldifficult groups in our school, since implementing PBLin 1989, and felt reasonably sure that other schoolswould have had experiences similar to ours. Given thedearth of medical education literature on dealing withdifficult groups, conclusions were drawn from studiesand theory-based articles and chapters in other fields,most emanating from business and psychotherapy lit-erature bases.

The second conclusion was that conflict is inevitableas groups grow through normal developmental stages.Through the years, theorists have proposed that groupsgrow through developmental stages as they mature. Asearly as 1965 Tuckman,1 having reviewed 55 studies,

Correspondence may be sent to Maurice A. Hitchcock, EdD, Division of Medical Education, University of Southern California School ofMedicine, 1975 Zonal Avenue KAM211, Los Angeles, CA 90033, USA.

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proposed that groups developed through defined stages.Although theorists seem to propose slightly differenttitles and descriptions for the stages, many similaritiesexist between the theories. Among these is that groupsexperience conflict from time to time and it is byworking through this conflict that a group matures.Our experience has been that many novice tutors be-lieve that when their tutorial runs smoothly (withoutconflict) it is functional, and that when it has conflict itis dysfunctional; this notion is not supported in thegrowth-through-stages literature.

The third conclusion was that dysfunctional groupsare those that get "stuck" in conflict stages. Keyton(1991)7 concluded from her study that groups thatbecome dysfunctional do so because they are unableto work through the conflict experienced as a normalcourse of development; they get stuck in conflict.When such a situation occurs, according to Keyton, thegroup takes on a particular dynamic or interactionpattern consisting of (a) an individual (primary pro-voker) in the group (may be the leader or tutor) beingblamed as the source of all the group's problem, (b)group members perceiving that the only solution is to"fix" the aberrant member, and (c) group membersbeginning to express negative emotions about thegroup and the primary provoker to others outside thegroup; they just "want out" of the group and "can't waittill the group is over."

The last conclusion reached was that proactive inter-ventions to prevent groups from becoming dysfunc-tional work best. When groups reach the stage of dys-function described previously, it is difficult orimpossible to get them to function normally again.According to the approach proposed by Friedman8

called "Upstream Facilitation", one should thereforefocus on proactive interventions to keep groups fromreaching a dysfunctional status. Two of the strategiesproposed seem particularly relevant for PBL tutorialgroups: (1) establishing group norms and (2) managingthe breakpoints in the group's development.

Setting group norms early in a group's life paves theway for smoother development. A group's beginning isa key moment in its life. Members are eager to orientthemselves to a new situation and are open to anydirection that will reduce uncertainty. Patterns are setin motion early that continue throughout the life of agroup. In this critical time of emerging patterns, Fried-man suggests two important interventions to steer thegroup in positive directions. First, the facilitator (tutorin our case) should make explicit his or her role in thegroup. Second, group norms (ground rules) should beelicited from group members. Friedman suggests aconscious process of setting group norms developed bySpich and Keleman9 as a way to prevent later confusion.Group members review 62 behaviors that have beenvalidated as distinguishing between effective and inef-fective groups (e.g., do a fair share of work) and are

encouraged to pick and choose from the list to identifya subset of the rules, which are relevant to their group.

Friedman's8 second proposed strategy is called"managing the breakpoints of a groups development."Citing research by Poole,10 Friedman describes groupsas evolving through developmental transitions, calledbreakpoints. Managing these breakpoints involves thefacilitator's use of one of three types of interventionsappropriately.

"Forward Interventions" are most appropriate whennormal breakpoints occur (i.e., shifts in topic or stageof problem solution). At such points, when the group ismaking normal progress, the facilitator might say noth-ing and wait for the group members to move on to thenext step, or might summarize what has occurred andoffer a suggestion, leading the group toward the nextstage of problem solving. When agroup reaches a delaybreakpoint, (e.g., students cannot synthesize the symp-toms of a patient into a coherent understanding of hiscondition), it is often useful for the facilitator to focusthe group's attention on a previous stage of the prob-lem-solving process (e.g., ask the group to make a listof symptoms they would expect to see if each of theirhypotheses were correct). Such interventions aretermed "backward interventions." "Present-centeredinterventions" are appropriate when a disruption break-point, such as a conflict or impasse, occurs in a group.At such breakpoints, a facilitator should stop the groupand focus attention on the here and now in the group(e.g., "let's talk about what is going on this group") untilmembers understand what has occurred, what needs tobe done, and progress seems assured.

Armed with the previous information about groupfunctioning but unsure of whether or how it applied toPBL tutorial groups, we launched a study of dysfunc-tional tutorial groups in our school. The purpose of thestudy was to generate strategies faculty can use to assessand intervene in difficult tutorial groups. A workshopwas organized for our experienced tutors to accomplishthis purpose. Our strategies were to (1) teach partici-pants the approaches from the literature previouslyreviewed, (2) give them opportunities to assess andintervene in typical difficult tutorial scenarios observedin our school, (3) gather feedback from participants onthe usefulness of ideas from the literature, and (4)generate further ideas from the experience.

Methods

Faculty experienced as tutors in the PBL curriculumat our school were invited to attend a 1-day advancedtutor-training workshop entitled "Dealing with Dys-functional Tutorial Groups." Eligibility for attendanceat the workshop required faculty to have been trainedas tutors via our required tutor training sequence andhave tutored at least one group of medical studentsthrough one of our curricular units (about 13 weeks).

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DYSFUNCTIONAL TUTORIAL GROUPS

The 23 faculty registered as participants included 13clinicians (3 psychiatrists, 4 pediatricians, 2 surgeons,3 internists, 1 family physician); 6 basic scientists (1biochemist, 2 anatomists, 2 physiologists, 1 pharmo-cologist); and 4 with other backgrounds (2 medicaltechnologists, 1 Master of Public Health, 1 Doctor ofEducation).

The workshop opened with a presentation of thefindings from the literature reviewed previously in thisarticle. Participants were then randomly teamed intofive groups (three groups of five and two groups offour), and assigned a trainer who remained with themthe rest of the day and coordinated their educationalexperience. Groups of trainees rotated through each offive stations (1 hr each) where students portrayed adifficult tutorial situation taken from a real experiencein our school. In each session participants had an op-portunity to assess the problem the tutorial group wasexperiencing, plan an intervention to correct the prob-lem, implement the intervention in the tutorial, and thenreceive feedback from trainers and students.

Upon entering a station, trainees were given a para-graph describing the tutorial group they were about toobserve but the problem to be portrayed was not iden-tified. Each station consisted of five 2nd-year studentswho had been trained to portray a specific difficulttutorial scenario by a "station manager" who was alsoa member of our faculty. The station manager served asthe tutor as the group portrayed the difficult tutorialsituation. When the students had acted out enough ofthe scenario to display the problem (up to 15 min), thestation manager called time out and dismissed the stu-dents from the room. The group trainer then led adiscussion with the trainees to identify the problem thegroup was having and to plan an intervention to correctthe problem; one trainee was selected to implement thegroup's intervention when the students returned. Stu-dents were then called back into session where theselected trainee served as tutor and tried the interventionplanned by the group of trainees. After a short time, thesession was halted and a debriefing was held in whichstudents, trainers, and trainees reflected on the experi-ence and the perceived success of the interventions.

The five station scenarios used in the workshop wereconstructed from actual tutorial experiences at ourschool observed by the authors. Both authors haveongoing responsibility to observe tutorial groups as partof the faculty development contract we have with fac-ulty at our school. We met and selected the five mosttypical situations from our collective observation expe-riences over the previous year. No attempt was made toselect student-induced versus tutor-induced problemgroup situations. In a dynamic small group such as atutorial, it is difficult and perhaps not important toreliably identify the origin of the problem or who is thecause. The important issue to consider is how tutors canintervene to prevent or correct the problem.

Station 1 consisted of a tutorial group one mightcharacterize as "apathetic." Students were focused onpreparing for upcoming Board exams; they were notadequately prepared for tutorials and discussed cases inshallow fashion. Students in Station 2 tutorial focusedstrictly on the biological aspects of the patient's disease;they resisted dealing with other issues (i.e., psychoso-cial) important to our curriculum. Station 3 had a dys-functional member who was frequently absent fromtutorials and came late and unprepared to others. Thedilemma in Station 4 involved one student becoming ascapegoat; she had developed a reputation as "a studentyou do not want in your tutorial group", which had beencarried into this tutorial by members who ostracized herand reacted incredulously to her comments. The groupin Station 5 had a student who divulged case solutionsprematurely to her tutorial group, spoiling the learningopportunities for other students; the tutor's confronta-tion with her caused a crisis in the group.

Station managers served as the recorders for this pro-ject. Using a standard protocol constructed by the authorsof this study, station managers recorded the various waystutors assessed the problems portrayed in their station andthe interventions tried. Following the workshop, theauthors summarized the various assessments and interven-tions. From this summary a model, which seemed toexplain the trends of interventions across the groups, wasconstructed using logical analysis.

Results

A summary of the problems identified and interven-tions attempted follows.*

Problems identified in Station 1 (apathetic group)included an inadequate learning procedure (e.g., no useof chalk or white-board, no thinking aloud, not discuss-ing case); a cynicism about the PBL process (e.g., doesnot prepare students adequately for Boards); and abelief that individuals study and learn best alone. Tocorrect these problems, tutors and participants referredto the ground rules set at the beginning of the group andreminded students that certain tutorial processes (i.e.,use of the board, thinking aloud) are nonnegotiable;directly addressed the anxiety of the group over prepa-ration for the Board exams by explaining that studentsin the past who had prepared well for PBL cases haddone well on the Boards; and challenged the notion thatindividuals learn best alone.

Participants rotating through Station 2 noted that thegroup focused exclusively on the biological issues ofthe case and avoided the psychosocial impact of diseaseon the patient and his family. This problem seemed to

A complete compilation of these problems and interventions isavailable from the authors upon request.

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stem from a basic rationalization by students that be-havioral issues are ambiguous, and that the literature isconfusing, difficult to find, and contains conflictingopinions. To address these problems, participantsstopped the student discussion of the case to encourageconsideration of other perspectives (e.g., impact on thefamily), personalize the case to students through roleplay of the physician and patient, and illustrate the biasof the discussion by labeling the various learning issuesconsidered by students.

Problems noted in Station 3 were that Paul, thedysfunctional student, was not "pulling his weight" inthe group and that had caused a crisis; other studentshad become angry and dissatisfied with the group.Participants also noted that the tutor had let the problemgo on too long without confrontation, which may havecontributed to a continuance of the problem. To correctthe problems in the group, participants suggested thatthe tutor (a) review, reiterate, and redefine the groundrules of the group in writing before continuing thetutorial; (b) have the group confront the problem withthe student by engaging students in brainstorming so-lutions to Paul's professed reasons for absenteeism (i.e.,no transportation, had to take a bus); (c) involve anoutside mediator in solving the group's problem; (d)refer Paul to others in the school (i.e., Unit Chair,advisor, therapist) for counseling; and (e) encouragestudents to share learning issues and not depend on Paulfor contributions to the group.

In the Station 4 tutorial group, which scapegoatedone of its members, participants noted the problems ofa passive tutor who had allowed a student to be ignored,and the student's reputation, which had interfered withher acceptance in the group. They also identified theproblem as one where both parties (the group and thestudent) were responsible. The group had isolated thestudent both verbally and physically (i.e., ignoring hercomments, talking away from her to the board). Thestudent had contributed to the problem by being tooquiet, disengaged, and making inappropriate com-ments. Participants attempted to correct the problem bytrying to involve the student in the tutorial (i.e., get herto be scribe, invite her into discussion, ask her to readthe problem). When that strategy failed, they stoppedthe tutorial process and confronted the problem directly.They first focused on setting appropriate ground rulesfor the group (e.g., everyone participates in discussion,all items suggested go on the board, everyone is treatedwith respect). They then engaged the group in suggest-ing ways to improve the student's participation (e.g.,talk early in the tutorial, do not wait till the mostplausible hypotheses have been exhausted).

Participants assessing Station 5 (group with memberthat divulges diagnoses prematurely), noted that thegroup was confused over the difference between PBLand traditional problem-solving, was seeking solutionsrather than attempting to understand basic mechanisms,

had violated the important nonnegotiable ground rulethat groups cannot skip steps in the tutorial process, andhad denied that a problem existed. These problemsstemmed from a dominant student in the group who wasfrustrated with the slowness of the PBL process and wasable to get others to support her shortcut. A variety ofstrategies were employed to address the problem: (1)review of the purpose and process of PBL with thegroup; (2) development of explicit ground rules to referto when the group goes awry; (3) exploration of therationale for keeping one's options open and consider-ing multiple hypotheses (e.g., comparing it to a physi-cian's clinical decision-making process); (4) gettingmembers to jot down their own hypotheses on paperand then asking for contributions from each; 5) explor-ing options for how the group can use the member totheir advantage; and 6) asking the student to not divulgethe diagnosis early.

Conclusions

Several conclusions emerged during the debriefingsession with participants at the end of our workshop.The focus of this session was to assess the usefulnessof ideas from the literature and generate further ideasfrom the workshop experience. A proposed interven-tion model was also constructed by the authors after theworkshop. The conclusions reached and the model pro-posed follow.

Developing Ground Rules IsImportant to the SuccessfulDevelopment of Tutorial Groups

A common mistake made by many tutors and newgroups is assuming they share a common understandingof the purpose and appropriate process of tutorials.They often discover this lack of agreement only afterthe group reaches a crisis. Setting ground rules throughsome deliberate process early in the group's existence,as suggested by Spich and Keleman (1985),9 serves twoimportant functions. First, ground rules can preventcrises from occurring in the group by establishing com-mon expectations. Second, if and when the groupreaches a crisis point, established ground rules can serveas an important reference for the group and tutor todiagnose the problem and decide how to proceed.

Although our faculty agreed on the importance ofgroup participation in the establishment of ground rulesfor tutorials, they asserted that there are several rulesfor PBL tutorials that should be nonnegotiable, and thattutors should be explicit in explaining these to studentsas a new tutorial group is being formed. The purpose ofthese nonnegotiable ground rules as seen by the facultyis to establish the group as a true PBL learning group.They include the following:

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DYSFUNCTIONAL TUTORIAL GROUPS

1. Attendance and punctuality are mandatory.2. Groups must use the chalk or white-board as

they study a case.3. All students in the group must think aloud to

allow others to benefit from their reasoningprocess.

4. Groups cannot skip steps in the deliberation ofcases—they must use all the steps (i.e., identi-fication of problems in case, hypothesizing, list-ing other information needed to confirm hy-potheses, identifying learning issues).

5. Groups must evaluate their process as a groupand as individuals on a regular basis (e.g., at theclose of each tutorial).

6. Groups must study illness as well as disease.

Tutors and Groups Should Deal WithConflict Directly As It Arises in theGroup

It is common for tutors to want to avoid dealing withconflict, to assume that if they do not attend to theconflict, it will resolve itself. It is also a commonmisconception among tutors that groups that runsmoothly (without conflict) are functional, wherasgroups that have conflict are dysfunctional. Both phe-nomena influence tutors and groups to avoid confront-ing conflict when it arises in the group. Our experienceas well as the literature on group functioning argue forthe opposite strategy. Avoiding conflict in groups runsthe risk that the group will become dysfunctional,

TUTOR RECOGNIZES PROBLEM IN GROUP

LEVEL 1 INTERVENTION:"CORRECT GROUP IN-PROCESS"

Tutor attempts to correct the problemby asking questions and/or makingsuggestions while the group continuesto focus on the Health Care Problem.• get ignored student more involved

by asking her direct questions.

• ask students ignoring psychosocialissues "How would you feel if youwere this patient?"

i^ fp rob lem persists^

INTERRUPT GROUP DISCUSSION OF CASE

IDENTIFY PROBLEM IN GROUP

• group must acknowledge that aproblem exists either by askingthem to identify the problem (e.g.,ask "What is missing? or What isthe problem?") or by tutor producingdata to support case that a problemexists.

LEVEL 2 INTERVENTION:"NEGOTIATE NEW APPROACH"

• tutor attempts to convince studentsof the wisdom of proceedingdifferently (i.e., emphasize theimportance of psychosocial issuesto the treatment of patient) orbrainstorm potential solutions withstudents in the group.

LEVEL 3 INTERVENTION:"INVOKE GROUND RULES"

Tutor may refer back to previouslyagreed upon rules by the group (i.e.,group is violating rules agreed upon)

ORTutor may invoke non-negotiableground rules for PBL Tutorials:• Attendance and punctuality are

mandatory.• Group cannot skip steps in the

PBL process.• Group must use the board.• Group members must do their

thinking aloud.• Group must evaluate its process

on a regular basis.• Group must study illness as well

as disease.

I^problem persists^

LEVEL 4 INTERVENTION:"SEEK OUTSIDE ASSISTANCE"• tutor or group may request

assistance of an outside mediatorto solve the problem in the groupor may refer an individual studentto a service in the school (i.e.,counseling, remediation).

•^Tfproblem persists^)

Figure 1. Dysfunctional tutorial groups intervention model.

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HITCHCOCK & ANDERSON

whereas dealing with it directly as it comes up offersthe opportunity for growth to greater maturity andsatisfaction by the group.

have resource people in the school (trained in groupprocess and PBL) to call on for consultation (a Level 4intervention).

Tutors Need to Intervene Strategicallyto Foster Positive Development in aGroup

The Intervention Model outlined in Figure 1 repre-sents our ideas, based on the experience of this studyand workshop, of the strategies tutors should use tointervene in groups that are at risk of becoming dys-functional. The model is based on a progression ofinterventions, each level being more intrusive, to ad-dress problems identified by the tutor. Level 1 inter-ventions represent attempts by the tutor to correctidentified problems while the group is in the processof discussing a case. Examples include asking a disen-gaged student questions to get her more involved,requesting students to identify information necessaryto confirm or reject their hypotheses, and correcting agroup trying to jump from listing hypotheses to iden-tification of learning issues. If the problem persists, wesuggest a Level 2 intervention in which a tutor inter-rupts the group's discussion of the case, identifies theproblem, and negotiates a new approach with thegroup. Level 3 interventions involve the tutor invokingground rules to correct a problem identified in thegroup—this intervention is more effective if the grouppreviously set explicit ground rules. We acknowledgethat the problems in some tutorial groups exceed anindividual tutor's and group's ability to solve the prob-lem themselves; in such cases, it would be helpful to

10.

References

1. Tuckman BW. Developmental sequence in small groups. Psy-chological Bulletin 1965;63:384-99.

2. Napier RW, Gershenfeld MK. Groups: Theory and experience.Boston: Houghton Mifflin, 1973.

3. Johnson DW, Johnson FP. Joining together: Group theory andgroup skills (5th ed.). Boston: Allyn and Bacon, 1994.

4. Tuckman BW, Jensen MC. Stages of small group developmentrevisited. Group and Organization Studies 1977;2:419-25.

5. Worshe! S, Coutant-Sassic D, Grossman M. A developmentalapproach to group dynamics: A model and illustrative research.In S Worshel, W Wood, J Simpson (Eds.), Group process andproductivity (pp.181-202). Newbury Park, CA: Sage, 1992.

6. Smith KK, Berg DB. Paradoxes of group life: Understandingconflict, paralysis, and movement in group dynamics. San Fran-cisco: Jossey-Bass, 1987.

7. Keyton, J. Who's annoying who? Problems in organizationalgroups. Paper presented at the Annual Meeting of the SouthernStates Communication Association, Tampa, FL, April 1991.(ERIC, ED 332 244)

8. Friedman, PG. Upstream facilitation: A proactive approach tomanaging problem-solving groups. Management Communica-tion Quarterly 1989;3:33-50.

9. Spich RS, Keleman K. Explicit norm structuring process: Astrategy for increasing task-group effectiveness. Group andOrganization Studies 1985; 10:37-59.

10. Poole MS. Decision development in small groups III: A multi-ple-sequence model of group decision development. Communi-cation Monographs 1983;50:321-41.

Received 28 July 1995Final revision received 8 May 1996

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