Moving from Restrictive to Progressive Learning Systems in Professional Healthcare Training

Moving from Restrictive to Progressive Learning Systems in Professional Healthcare Training

Julia is a psychodramatist, educator and mental health clinician. She is currently completing her PhD research into spontaneity within groups. This is an excerpt from her psychodrama thesis.

When a trainer works with a group for the first time there are dynamic forces already in play. The trainer approaches the group with a particular warm up and vision for the training that is going to take place. Within the group there will be particular roles and role relationships that participants will have warmed up to. There is a curriculum or negotiated objectives, which provide a basis for the work that the trainer and group will do together. This paper describes how these dynamics come together in the first session of the interpersonal skills module of a 3-week training program in palliative care for registered nurses.

Three Sections in this Example of Spontaneity

Training:
• group dynamics: at the beginning of the session which contribute to a restrictive learning system. Observations are based on the framework developed in the Psychodrama Section at Saint Elizabeth’s Hospital, Washington D.C.(Clayton, 1989, p.2).
• sociometric interventions: used to build a progressive learning system.
• warming up: to a professional role system of active listening.

Group Dynamics, Observations At The Beginning of The First Session This is the first of seven 2-hour sessions of interpersonal skills training in a 3-week training program in palliative care for registered nurses. There are 13 people in the group - 2 men and 11 women with ages ranging from early twenties to mid fifties. This session takes place in the second week of the course and is the first training session for the trainer with this group. The training so far has been of a didactic nature with lectures and discussion groups on physiological nursing care of a dying person.

There are chairs and large wooden tables arranged in a semicircle at one end of a large hall. There is a lectern at the front with another table beside it and a chair behind it. All group members are present - some chatting in small groups, others sitting quietly. The air is very humid.

Tina, the course co coordinator, is standing speaking in hushed and solemn tones to Evie and Linda, two immaculately groomed young women, who have downcast eyes and look uncomfortable. The trainer walks to the front of the hall and she is introduced by Tina in a respectful way. There is a stirring of tentative interest in the midst of a prevailing listlessness. Jed and Mary, two matronly, earnest looking women pick up their pens and Jed moves a dictionary in front of her. The trainer gives an outline of the areas of work that will be covered in the sessions on interpersonal skills. A couple of people write a heading on the blank page in front of them. Fran has a gentle smile on her face and a far away look in her eyes.

The trainer states the purpose of the first session as: to get focussed on what particular interpersonal skills each person wants to develop and for group members to connect up with each other in a good way to do this work. She then asks Evie, who is looking alert and interested, whether she can get on board with this - Evie looks taken aback and a ripple of surprise runs through the group. Linda is looking curious and pleased. Evie steals a glance at Una and Barb, two silver haired, solidly built women who stare impassively ahead. Evie nods her head quickly. Adam and Peter exchange a glance and their eyes twinkle. Carol comments in a low voice that it sounded better than getting writer’s cramp. Erin nods and laughs.

The trainer then stands up and invites everyone to come to the back of the room and she walks purposefully towards it. There is a moment of hesitation and uncertainty. Most people look at Una and Barb for guidance and after a couple of moments they stand up and once they have moved other group members follow - Erin and Carol walking quickly and purposefully, Mary and Jed giving their textbook a longing look as they go.

Discussion of Group Dynamics:

The warm up of the group initially conveys the expectation that group members will be learning knowledge from the trainer. Body language and attention given to pens and papers demonstrates they expect to be writing and the physical environment lends itself to a lecture style format with large desks and a lectern. Participants are warming up in a somewhat desultory fashion to being dutiful scribes. This is a pretty common situation for a trainer working with a group for the first time in an educational setting. We can say that there is a culture of dependent learning that contributes to a restrictive learning system.

Dependent Learning:

Scribes learn in a dependent way where the source of knowledge and authority lies outside of them and resides in another person. In the first week of this course group members had been learning new facts, which required them to record details for reference and eventual integration into their nursing interventions. In undergraduate nursing training, as in much professional training, the role of scribe is developed out of necessity and is adequate.

The Contribution of Dependent Learning to a Restrictive Learning System:

The dutiful quality in the role of scribe in this group conveys a sense of the giving up of personal authority and valuing of own thinking. This is an element of a restrictive learning system where the capacity of each person to think and act independently is diminished. Another element of dependency contributing to a restrictive learning system is that of looking for affirmation before speaking as one of the group members does when the trainer speaks to her and she looks at senior members of the group.

The Contribution of Hierarchy to a Restrictive Learning System:

At the beginning of this session two of the younger nurses were being admonished for asking questions the previous day. They were told that they were being smart and to get back in their place and to stay there. There was a welldefined hierarchy within this group based on length of time in the nursing profession. This was regardless of actual competence as some nurses had postgraduate qualifications that the nurses heading this hierarchy did not have. When a hierarchy is established and maintained, leadership in the group is through position in the hierarchy. This limits the range of thinking that can occur as it can only come from a small number of people rather than drawing upon the resources of all members of the group. Clear thinking is diminished due to anxiety and dependence on approval by those at the top of the hierarchy. The value placed upon your words depends on your position in the hierarchy. In this group authority is initially assigned to the trainer and senior group members. As all of the group are registered nurses they have already developed a set of roles around their interpersonal skills, which are part of their professional identity. When they are acting as if they need to write they are not warmed up to the skills that they already have. Given the patterns of restrictive learning in the group it is clear that the group members would benefit from interventions to increase their spontaneity.
 

Sociometric Interventions

With the movement out of their chairs there is a change in energy within the group - an increased sense of life. The trainer chats to Una and asks her how long she has been a registered nurse - she replies 30 years. A sociometric line is set up for length of time in nursing and as people worked out where they belonged there is goodnatured chatter and some physical contact. People placed themselves as shown in Diagram 1 above.

The trainer comments on the value of having such an extensive time frame of experience in the group. She asks the group what abilities they see Una and Barb bringing to the group. Peter suggests that they know a lot about nursing, Linda looks intrigued and thoughtful and then says in a strong voice that they have plenty of experience - Una looks surprised and pleased, Barb remains impassive. Then the trainer asks what abilities Linda and Evie bring to the group. There is silence and a thoughtful atmosphere - Evie crosses her arms and moves from one foot to another. Linda looks worried. After a bit Adam says that they know about up to date techniques in nursing. Carol says that they know how to write nursing care plans - Linda looks relieved and Evie goes very red. Group members think about what motivated them to be a nurse and get together with a person from a different end of the scale to them to discuss this. They begin chatting in an animated fashion.

During the next part of the session people place themselves in a sociogram on where they travelled from geographically to get to the session. This brings out different aspects of their work, some people had travelled from remote areas - it became clear some people worked in very isolated roles. They have a chat with a colleague on one difficulty they overcame to get there that day. These are brought out in the group. Then group members get together with another person they don’t know very well and discuss with them areas of interpersonal skills they want to build on in the course.

After a few moments the trainer asks group members to pause their discussion, for Adam and Fran to stay just as they are at that moment and everyone to observe them. Is their relationship positive, neutral or negative? There is general affirmation that their relationship is positive. The trainer suggests that Adam was being an effective listener with Fran who nods vigorously. Group members identify what they see Adam doing nonverbally that demonstrated he is listening to Fran - eye contact, body leaning forward, looking friendly and being relaxed. The work of Gerard Egan (1985) on nonverbal listening skills is then introduced with reference to these. Group members are invited to reflect on whether they thought the colleague they were with was listening to them and what they were doing that brought them to this conclusion. There is an intrigued silence - the trainer suggests people look at their colleague now and carry on communicating their observations. Each person then presents their colleague to the group including one interpersonal ability that they had experienced with their colleague in the interaction. Laura makes a playful comment about her partner’s ability to marry a good looking man. Everybody laughs.

Analysis of Subgroups:

An analysis of roles and of subgroups assists the trainer to be alert to the changes in role and role
relationships that will support a progressive learning system and recognise the nature of the learning system that they actually encounter. Underlying role theory is the belief that all human beings at any stage in their life are capable of developing a wider range of ways of creative being. Role theory is infused with hope. There is value for the trainer in having an optimistic way of thinking about human development when confronted with difficulties in training situations. Role analysis provides a means of thinking about these to guide the trainer’s choice of interventions. The following description of subgroups and roles is based on what participants were doing in the first part of the session. The Diagram 2 above depicts where they were sitting in relation to each other.

The Data upon which these Descriptions are Based:

• irrepressible lovers of life: exchanging glances, comments and smiles with twinkling eyes.
• anxious students: worried focus on pens, dictionary, textbooks and chairs.
• sensitive dreamer: empathic non verbal language, far away look in eyes.
• down to earth doers: alert body language exuding ‘lets get on with the job’ attitude.
• stolid matriarchs: sitting stolidly, observing others and modifying their behaviour through nonverbal expressions of approval or disapproval.
• curious explorers: interest shown toward new ideas, light of life in their eyes.
• playful gossip: cheeky jokes about other group members’ personal lives.
• rule enforcing autocrat: telling off younger students in hushed and stern tone, thinks that young students should keep silent and respect their elders.

All of these subgroups have the potential to support a restrictive learning system if they remain static within the group. Irrepressible lovers of life can be so warmed up to fun that work may not get done. Sensitive dreamers can focus mainly on visions and ideas without accompanying actions. A rule-keeping autocrat runs a tight ship with not much flexibility. A playful gossip can warm up to talking about people rather than to them. Curious explorers can be so focussed on finding the next thing they may not integrate the new thing they’ve just encountered. Down to earth doers can warm up to activity without reflection and stolid matriarchs can stifle new life.

Interventions that Build Progressive Roles:

Beginning with the established hierarchy and then facilitating people getting together with someone in a different position helped to cut across the interactional patterns which previously existed in the group. The level of spontaneity in the group increased markedly as people progressed through the three different pairings around different criteria. Asking people to identify and publicly communicate an interpersonal ability they perceived in a colleague lifted self-esteem and warmed people up to their strengths.

As people become more aware of the observations they are making of the nonverbal communications of their colleagues, and then communicate these, they warm up to the roles of objective observer and constructive communicator.

The trainer is paying attention to a systematic process of warm up in which people move from simple to more complex interactions so that they experience ‘in as natural a way as possible’ progression to active involvement with each other which will move into specific clinical situations during the sessions that follow. The session has been planned to link in with the curriculum objective of the first session of further developing ability to be an active listener.

Warming Up to a Professional Role System of Active Listening

The purpose of the warm up and interventions to build the sociometry and spontaneity in the group is to develop the role of active listener. This role is an integral foundation for role development in the future sessions on interpersonal skills in this course including counselling, mental status assessment, family assessment and conflict management.

The following role system (Diagram 3) is of an active listener. It portrays the range of roles which the trainer works to warm participants up to, thus further developing their ability to listen effectively in a variety of situations. This is done in the session by warming participants up to finding out some things about their colleague (naïve inquirer), thinking about what occurred in their interaction (reflective thinker and objective observer), what they valued in each other (clear seer and enjoyer of life) and stating some of their observations in a constructive way (positive communicator).

This role system is important as it has guided the planning of the session and is directly linked
to the learning objectives. The focus is on warming up the group in the first of a number of training sessions on interpersonal skills. The warm up of group members at the beginning of a training session to each other, themselves, the work and the trainer will have an impact on the learning system that develops. The development of roles from the active listener will assist the learning system to move from restrictive to progressive.

Warming Up To Enactment:

As we have seen the group has been operating in a dependency learning system with a lack of independent thinking and action and where spontaneity is low. There is little free and flexible expression between group members. In such a restrictive learning system there is no place for naive inquiry. The challenge for a trainer is to work with the motivation of the group members to learn in such a way that they warm up to roles and group functioning in which a progressive learning system is created and spontaneity training effectively used.

People have varying degrees of enthusiasm in participating in role-play and by its nature spontaneity training can be equated with roleplay in people’s minds. Although there are marked differences for the trainer and participants between spontaneity training and role play it can remind them of previous experiences - both positive and negative. For some people the mention of the word role provokes a fear of having to ‘act’ a role and not feeling able to do this. It is crucial that the trainer lay the groundwork in the early stages of a first training session to establish a learning system within the group in which people become involved in action in a meaningful and reflective way. This is done by setting clear expectations for the participants. They are not being expected to ‘act’ anything different to who they are. The trainer is attempting to increase their warm up to particular professional roles by tuning into and refining their abilities. The trainer deliberately does not refer to role play or actively try to address past negative experiences or fears - this would be an impossible task anyway - she is focussed on creating a positive learning experience in the present that can be built on in future sessions.

As we have seen it is important to create a resilient environment within which people will be able to try out new interpersonal skills, gain confidence in these, be able to make mistakes and not be judged or made to feel stupid by their colleagues or the trainer. Exploration, light heartedness and thoughtfulness are encouraged. The use of sociometric exercises gets people out of their chairs and warmed up to acting.

The aim is to warm people up to each other and the work of the session. It is also immediately beginning to establish a working environment for the rest of the sessions in which people act and interact. Rather than saying there will be action the trainer does it. Spontaneity training begins the minute the session starts.

Recommendations for Trainers on the Use of Spontaneity Training

It is useful to have some guiding principles in mind when using spontaneity training. The following recommendations have been derived from working on this paper.

• Start on the front foot with the use of interactional activities in the group - do not be apologetic or tentative. Asking people if they want to do enactments will raise indecision in them.
• Use sociometric exercises which move from simple to complex interactions and from superficial to more revealing criteria.
• Include a criteria of difficulty and ability used in overcoming this, for example, one obstacle overcome to get to the session. This contributes to the development of a learning system where obstacles are acknowledged.
• Link enactments clearly with the learning purpose of the session and participants’ own clinical practice.
• Structure enactments to link in with curriculum objectives and include choice of the details of the roles enacted for participants to bring their own experience as practitioners or of patients that they have worked with.
• Take time to warm people up adequately to the roles they have chosen.
• Include reflection and discussion on role development.
• Strengthen your own capacity to be present and not reactive to your own discomfort when there is turbulence and/or resistance in the group.

Conclusion

There are moments in this session where the trainer is out on a limb. At these times she cannot depend on the approval or the immediate cooperation of the group in what is suggested. When a group is expecting a certain style of learning it requires some readjustment for people when it becomes clear that their expectations are not going to be met. When a particular structure is operating within a group there will be some anxiety when this is not actively upheld. During this period of change in warm up of the group the trainer needs to be able to sustain their warm up to the work that they are doing while the turbulence and discomfort is present in the emotional climate of the group. Spontaneity training may result in an increased awareness of elements contributing to a restrictive learning system. While awareness in itself does not guarantee any change in functioning, a greater level of spontaneity may result when awareness is combined with active practice of new responses in a range of interpersonal situations. The vision is of professional healthcare workers learning and working in a progressive learning system where they work with purpose and flexibility and contribute to effective patient care and ongoing workable structures.

References

Clayton M (1989), Group Work Training Manual, The Australian College of Psychodrama, Melbourne.
Egan G (1985), Exercises In Helping Skills: A Training Manual to Accompany The Skilled Helper, Brooks/Cole Publishing Co., California.