The Role of Inclusion in Collaborative Learning

Abstract

Collaborative methods for learning such as team-based learning, case-based learning, and problem-based learning have become leading methods for active learning within the field of health professions education. Critical thinking and exposure to diverse perspectives within a group are highlighted as important benefits of team-based learning. However, without consideration of the potential socioemotional, behavioral, and team dynamic challenges associated with this format of learning, the tenets which support a welcoming learning community can begin to deteriorate. In this essay, authors highlight the core concepts of growth mindset, psychological safety, and culturally responsive pedagogy within a framework of 1) what learners should know and 2) what educators can do, to co-create an inclusive collaborative learning experience.

Collaborative methods for learning such as team-based learning (TBL), case-based learning (CBL), and problem-based learning (PBL) have emerged as important tools in health professions education. As students work through clinical cases, they engage in active learning and critical thinking [1]. By integrating into the small group structures, learners build skills in teamwork and communication. Taken together, in collaborative learning settings, students acquire a diversity of problem-solving approaches, while building the interpersonal skills necessary to work as part of an interdisciplinary health professions team.

Despite the potential learning benefits and increasing incorporation of collaborative methods in medical education training, there are also important socioemotional, behavioral, and team dynamic challenges associated with this format of learning [2]. Without careful consideration of these features, the tenets which support a welcoming learning community can begin to deteriorate, detracting from the overall goals of team-based learning.

When grounded in the concepts of growth mindset, psychological safety, and culturally responsive pedagogy, team-based learning can be an effective teaching method that enhances students’ sense of belonging in medicine [3–5]. Here, we apply a framework for (1) what learners should know and (2) what educators can do, to co-create an inclusive collaborative learning experience.

Inclusive Learning for the Individual Student

What Learners Should Know

Health professions students accustomed to lecture-style teaching and educational settings focused on individual performance may be less familiar with collaborative learning methods [1, 6]. For some students, adapting to new methods of content delivery and the flipped classroom model can serve as a novel learning challenge. As explained by one first-year medical student: “…it’s a new way to learn, not like going to lecture and then like cramming before the exam. It’s like a real continuous learning process, that I think it does take some adaptation to get accustomed” [7].

When students encounter challenges associated with collaborative learning methods, maintaining a growth mindset, or the belief that one’s success can be improved through persistence and effort, may be an important step in learning [8, 9]. In preclinical settings, medical students with a growth mindset expressed enhanced learning goals and a greater commitment to lifelong learning [10]. In the face of setbacks, growth mindset is also valuable in reducing learners’ risk of stereotype threat, a thought process which can deplete cognitive resources and interfere with one’s sense of belonging [11].

Students should be aware of the steps for accessing educational resources which inspire a mindset of growth and support academic success. Learners can seek assistance in the form of peer tutors, online learning materials, and academic coaches [7]. Many trainees have found academic coaching to be helpful in developing effective approaches to team-based learning: “Before medical school…if I scored high then it must be a reflection of me doing well. Talking with my academic coach helped me reflect on the strategies I was using and what was working and what wasn’t. I could take a step back and kind of get back on track” [7].

What Medical Educators Can Do

Faculty can encourage students’ growth mindset by providing feedback and assessment which mirrors the goals of collaborative learning methods [8]. Educators can evaluate students based not only on whether they have arrived at the correct solution, but also on how constructively they contributed to the problem-solving process within their team.

Additionally, creating opportunities for students to reflect on areas for personal improvement is a way to promote a growth mindset [7, 12, 13]. A qualitative study which captured perspectives on mindset and reflection highlighted a “lack of time” as a theme related to limitations for reflective practices: “It is easy to subconsciously reflect on things, it’s harder in the pace in med school to sit down and say, okay, let me think about what I can do better. We probably should do that more, but that’s hard to do” [7]. Despite the time barrier, engagement in deliberate reflection was associated with an increase in anticipated use of goal setting and application of active learning strategies for students in a primarily collaborative learning-based curriculum [7].

Inclusive Learning for the Small Group

What Learners Should Know

When students share ideas and personal experiences related to course content in their small groups, it can serve as one of the most enriching features of collaborative learning. This process, however, requires the establishment of a psychologically safe environment, one in which students feel comfortable voicing different perspectives and engaging authentically without fear of judgment [4, 14].

Trainees in collaborative learning spaces have expressed feelings of exclusion during group discussions because of comments made by peers [15]. One student described an encounter where a joke was made about sexual orientation: “…it sometimes gives me a little uncomfortable feeling, an unsafe feeling, even though it wasn’t directly aimed at me…” [15]. When these interactions occur within collaborative learning spaces, students’ willingness for future engagement can be negatively impacted, with downstream effects that compromise learning for all [14, 16]. On the contrary, moments of bidirectional growth can result from thoughtful discussions related to interpersonal differences. In response to a cultural misconception voiced by a peer, one student explained: “…when they asked this question and I provide my input, a certain understanding arises, and then you have eliminated that prejudice a little more” [15].

While not all students initially possess the proficiencies necessary to prevent and respond to challenging team interactions, collaborative learning offers opportunities for longitudinal growth in this area. To facilitate development of these skills, students can create classroom agreements which include behavioral standards essential for a climate of psychological safety in learning [17]. Together, learners can decide on best practices for peer engagement such as active listening and mindful, non-judgmental word choice [8, 14]. Over half of learner communication is thought to be non-verbal; thus, attentiveness to body language and eye-contact are often included in classroom agreements [8, 17]. Finally, resources in the form of microaggression and teamwork workshops or e-trainings can also be made available to help educate learners about small group best practices [16].

What Medical Educators Can Do

In addition to incorporating concepts of growth mindset and psychological safety to support a climate of inclusion, educators can integrate principles of culturally responsive pedagogy to enhance the content and organization of collaborative learning sessions. The purpose of culturally responsive pedagogy is to teach in a way which emphasizes students’ differences as an asset to the classroom community [5]. For example, educators may invite learners to exchange introductions, preferred names, and pronouns to encourage recognition of the diversity within each collaborative learning small group. By facilitating team-based structures where learners alternate tasks as the notetaker, reporter, or moderator, educators can support a sense of interdependence.

The case content presented by medical educators creates additional opportunities to support culturally responsive pedagogy. By representing a diversity of patient demographics, educators invite learners to share relevant aspects of their own backgrounds, while integrating concepts of cultural humility in patient cases [18]. In a problem-based curriculum, linking specific cultural and demographic descriptions to patient cases through the use of “patient ID cards” was found to stimulate discussions of the important social and structural healthcare considerations for patient scenarios [19]. Qualitative results of the study revealed students’ perceptions of the intervention: “I thought that the patient ID cards included with our PBL cases were very diverse and representative of the vast array of demographics we may come across in our future clinical practices” [19]. Importantly however, ensuring that diverse patient representation is paired with discussions of potential social determinants is essential to prevent the reinforcement of stereotypes and bias. As described by one medical student in a separate study: “I felt like a lot of the CBL cases attempted to be more inclusive by adding names and pronouns, but that’s where it stopped. It didn’t feel like the case really addressed anything beyond that or health inequalities that could have been experienced by patients” [15].

Prior studies suggest that many faculty may feel inadequately prepared with the language or skills to integrate culturally responsive content in collaborative learning sessions. Educators often fear making mistakes when choosing activities and content [20]. Engaging in faculty development workshops can help cultivate skills in inclusive teaching concepts and curriculum development [20]. Obtaining feedback related to inclusion through students’ course evaluations can be a way to understand areas for growth in the learning climate. Educators can also use validated instruments such as the Belongingness Scale or the Promoting Diversity, Group Inclusion, and Equity tool to enhance inclusion within a team-based curriculum (Fig. 1) [21, 22].

Fig. 1.

Checklist for Inclusion in Collaborative Learning

Conclusion

Cultivating inclusion through principles of growth mindset, psychological safety, and culturally responsive pedagogy serves as an important step toward achieving the goals of collaborative learning in medicine.

Students should understand the role of mindset in overcoming individual learning challenges and accomplishing academic growth. Learners should be familiar with how to engage in peer interactions which promote psychological safety and invite contributions of others [14, 15].

Medical educators can support students’ growth mindset by providing feedback on their learning processes and allowing time for reflection on areas for improvement [7, 9]. By implementing culturally responsive teaching strategies, educators can highlight students’ differences as essential to the classroom community, encourage equitable student participation, and offer learning opportunities for cultural humility in patient care [2, 4, 14].

Immersion into a collaborative educational setting where principles of inclusion are intentionally embedded in the course content and methods may have transformative effects on the ways in which future physicians teach trainees, care for patients, and grow together in medicine. When paired with strategies inspired by inclusion, team-based learning is an educational tool that reinforces the principle that everyone is welcome at the collaborative learning table.

Declarations

Conflict of Interest

The authors declare no competing interests.