Medical Educational Effect of Group Encounters

- - Hiroko Itatani^.

Department of Comprehensive Patient Care, Comprehensive Diagnosis and Therapeutics,

Graduate School of Tokyo Medical and Dental University,

1-5-45 Yushima Bunkyo-ku, Tokyo 113-8549, Japan

coauthors: - Takehiko Kikkawa

National Institute of Mental Health

- Kazunori Takeda

Institute of Disability Sciences, University of Tsukuba

- Yugen Shinpo

Tokyo Seitoku University, Japan

E-mail: fwhw0033@mb.infoweb.ne.jp
Eubios Journal of Asian and International Bioethics 12 (2002), 123-128.

Editorial note: Further tables being put on-line

Abstract
Ever since the Long term Care Insurance System was introduced in Japan, training and qualitative enhancement to the nursing care given by health professionals to the elderly has been requested. It is necessary to train health professionals to recognize the psychological and physical states of the elderly persons they are caring for. An education program that centers on a clinical education is necessary for this but has not been developed in Japan. This research aimed at clarifying the present situation of structural group encounters and when after doing structural group encounters at the Medical Treatment Health Welfare Training School if the attitude to the practice had changed. An evaluation was made using the Kagoshima University Clinical Practice Standard with 30 students using structural group encounters, and 30 students not using encounters. An POST-TEST comparison of the group not using encounters with the group using them, a significant difference was seen in "The plan for a day could not be properly made" and "My opinion cannot be easily communicated", etc. It is supposed that after experiencing structural group encounters, the students may perform an objective self-valuation and a review of care technology that leads to enhancing the learning effects of structural group encounters. This may be effective in transforming the attitude to clinical practice education.

Key words: Group encounter, Clinical education, Educational intervention, Attitude transformation, Health, Medical treatment

Introduction
Professional medical health treatment supporting senior citizens is insufficient in Japan. We should hurry to produce professionals who can accommodate the aging society and qualitatively enhance their education. Knowledge and technology are necessary for the medical workers and caregivers, and clinical practice is indispensable in the nursing training process. Highly developed expertise and ethics are given through clinical practice training. Three months of clinical practice in a social welfare facility is required in universities and schools for training caregivers. The student workers should participate in the conference and are requested to make overall judgments in the special nursing homes for the aged and health services facilities for the elderly where they are trained. However, very few facilities exist where the students carry this out. The educational intervention method aiming at an attitude transformation where the students show a positive attitude is necessary for clinical practice. In this research, we paid attention to introducing structural group encounters into the class as a way to unite the experience of care practice and the theory of nursing education. Structural group encounters were introduced to the class, analyzed and discussed on the merits for clinical practice.

Method
The groups were 60 second year health care students from a university nursing welfare department in Tokyo (15 males, 15 females, average age of 19.5 years in the encounter group, and 15 males, 15 females, average age of 19.9 years in the non-encounter group). The period was from December 1998 to November, 1999. They were asked to describe "their most embarrassing scene" in the 30-day care practices and present the reason for choosing the scene and their concern in the scene. The students were instructed to understand that mutual understanding with those who are in need of care is important. The teacher explained, with examples, that there are individual differences between the characters of people who are in need of care and their life environment. Appropriate support was given by looking back at the actual nursing scene the student experienced (Fig. 1 and Fig. 2). Before and after conducting structural group encounters, we determined the attitude change in clinical practice using the test form from the Department of Medicine, Kagoshima University. The test form by the Department of Medicine, Kagoshima University is a five point evaluation scale consisting of 24 items (Table 1). The students select one of the five answers. t-test of the mean difference was used for statistical analysis of the results. Statistical software used was SPSS 10.0J for Windows.

Results
The differences before and after structural group encounters are shown in Tables 2 and 3. For anxiety and worry about going to facilities for nursing practice, the answer, "I felt no concern and worry" increased from 3% to 30%. With anxiety and worry about the atmosphere at facilities, "I felt much anxiety and worry" decreased from 37% to 0%. The option "I felt no anxiety and worry" about attending to senior citizens increased from 3% to 43%, and "I had little anxiety and worry" increased from 3% to 43%.. "I felt very little" anxiety and worry about speaking with the senior citizens decreased from 47% to 0% and "I felt very much" decreased from 10% to 0%.

Regarding refusal from the senior citizens, "I was refused a little" decreased from 30% to 3%, and "I was refused very much" decreased from 10% to 7%. Regarding not getting along well with the families of the senior citizens, "Very much" decreased from 50% to 0%, and "Do not know" decreased from 33% to 27%. In response to not getting along well with the doctors, "Very little" decreased from 30% to 10%, and not getting along well with the nurses, "Have no such cases" increased from 3% to 20%. For the chief matron and the caregivers, "Have no such cases" increased from 0% to 20%.

With home helpers, "Have many cases" decreased from 37% to 0%, and "A little" decreased from 27% to 0%. In not being able to make a care plan, and practice and evaluate it in the care giving process "A little" decreased from 40% to 10%, and the answer, "Very much" decreased 30% to 0%. For not being able to properly make a plan for a day, "Very much" decreased from 50% to 0% and "A little" decreased from 30.0% to 6.7%.

Table 1: Questionnaire. From Department of Medicine, Kagoshima University, a five point evaluation scale consisting of 24 items.

Questionnaire: Please check the appropriate value.	No uneasiness	There is hardly any uneasiness	Neither	There is a little uneasiness	There is great uneasiness
1. Reluctant to go to facilities for the nursing practice.	1	2	3	4	5
2. Did not become familiar with the atmosphere of facilities.	1	2	3	4	5
3. Reluctant to receive the aged.	1	2	3	4	5
4. Cannot talk with the aged.	1	2	3	4	5
5. Refused by the aged.	1	2	3	4	5
6. Cannot get along well with the aged.	1	2	3	4	5
7. Cannot get along well with the doctor.	1	2	3	4	5
8. Cannot get along well with the nurse.	1	2	3	4	5
9. Cannot get along well with the clinical leader.	1	2	3	4	5
10. Cannot get along well with the other staff.	1	2	3	4	5
11. Cannot make a care plan, and practice and evaluate it in the nursing care process.	1	2	3	4	5
12. Cannot properly make a plan for a day.	1	2	3	4	5
13. Cannot complete the plan for a day in time.	1	2	3	4	5
14. Cannot use the nursing care technology well.	1	2	3	4	5
15. Cannot fill out the nursing care daily record and the temperature chart.	1	2	3	4	5
16. Cannot prepare a training record	1	2	3	4	5
17. Cannot transfer and/or report the duties.	1	2	3	4	5
18. Cannot express my opinion.	1	2	3	4	5
19. Cannot understand the diseases of the aged.	1	2	3	4	5
20. Cannot answer questions from leader.	1	2	3	4	5
21. Cannot understand what to do.	1	2	3	4	5
22. Can do nothing but just watch nursing care.	1	2	3	4	5
23. Some things were not taught at school.	1	2	3	4	5
24. Cannot be a care worker.	1	2	3	4	5

Guidance
The teacher explains the purpose and notes of the class of the structural encounter group.

↓

Exercise 1
Exchange of self introduction cards

Purpose
1. The merit not noticed is noticed.

2. Any tensions between members of the class are solved and the class is untied.

↓

Exercise 2
The scene with the person practicing is embarrassed is announced according to the described sheet.

↓

Exercise 3
The impression to which looks back is announced now after the scene when the person practicing was most embarrassed is announced.

↓

Exercise 4
The student who hears the announcement describes their own comments and passes to the speaker.

Comment by the teacher

↓

Summary by teacher
↓

To the following speaker
Figure 1: Procedure of class by which the structural encounter group is introduced

Regarding problems completing a plan for a day in time, "Very much" improved from 33% to 0% and "A little" decreased from 30% to 7%. With cannot use the care giving technology well, "Very much" decreased from 33% to 0%, and "A little" decreased from 30% to 6%. For cannot fill out the nursing care daily record and the temperature chart, "Have few such cases" increased from 7% to 53% and "No such cases" increased from 0% to 17%. In difficulty preparing a training record, "Have almost no such cases" increased from 0% to 53%. For not being able to transfer and/or report the duties, "Have almost no such cases" increased from 0% from 30%. With cannot get my own opinion across, "Have almost no such cases" increased from 0% to 40%, "A little" decreased 47% to 0%, and "Have such cases very much" decreased from 27% to 0%. "Do not know" increased from 10% to 33% for cannot understand the diseases of the aged.

The option cannot answer the questions from the leader increased from 0% to 40% for "Have no such cases". Not understanding what to do increased from 0%to 30% for "Have no such cases". Can do nothing but just the watch caregivers and something was not taught at school increased from 0% to 33% for "Have no such cases". Cannot be a caregiver decreased from 33% to 0% for "No such case".

In summary the results show that anxiety and worry about going to facilities were greatly reduced. The students felt more comfortable communicating with the senior citizens, their families and the medical staff. They felt that they were more competent in creating and completing care plans and filling in caregiver daily records and temperature charts. Their overall confidence in their knowledge improved to the extent that they did not feel apprehension about expressing their views and felt that they were better understood.

Figure 2: Verification Sheet

Discussion
Abroad, in the field of medicine and medical education, group encounters and unit studies to find a solution to a problem are advanced.^22-81) A teacher plays the role of a coordinator, and the study method progresses to a lesson centering on group work and discussion. In the lesson, an exercise is conducted to consider a target setup and method required to deepen the understanding of a patient which produces the effects of raising a student's study volition and understanding a patient's feelings and acquiring a deeper perspective. In this study as well, such attempts have led to deepening the understanding of the feelings of patients and old people who receive care. The option cannot answer the questions from the leader increased from 0% to 40% for "Have no such cases". Not understanding what to do increased from 0%to 30% for "Have no such cases". Can do nothing but just the watch caregivers and something was not taught at school increased from 0% to 33% for "Have no such cases". Cannot be a caregiver decreased from 33% to 0% for "No such case".

It is thought that feelings of self-respect were improved by promoting consciousness of the work through structural group encounters. That is, it is thought that the student related to the exercise by learning interpersonal relationships, and empathizing with the experience of others. The structural group encounter is one of the experience types of education methods.^11-13,^18-21) This study considered how using structural group encounters, and looking back at what had been experienced by clinical practice, affected the student's view of clinical practice. In POST-TEST, there were significant improvements in some of the items of caregiver technology; "Cannot complete the care process that forms care plans and carry out practice evaluations", "Cannot properly prepare a plan for a day", "Cannot finish the plan for a day in time", "Cannot use caregiver technology", "Cannot fill out a caregiver daily record and a temperature chart", "Cannot prepare the practice record", "Cannot properly transfer the duties and report", "Cannot get my own opinion across" and "Cannot understand the illness of the people who need care".

When the students fall short in fully utilizing the knowledge and technology acquired in care technology lectures according to the condition of people who need care in a clinical practice, structural group encounters lead to performing an objective self-valuation and care giver technology is improved. The result may indicate a request from the students of the need for experience-type education. This suggests that lessons centering on lectures using a textbook have limits in the understanding of the curriculum where the subjects include personal assistance and caregiver practice. The main purpose of experience type education, such as structural group encounters, is to achieve a deeper understanding through experience. In a case report about implementing experience type education in the medical education for terminal care, the virtual experience of a small group in a non-structural group encountering free discussion, including the VTR viewing of "Care exceeding a cure " produced by the United States hospice association, led to helping the students understand.^{1-10, 14-17} ⁾The execution of the structural group encounter can be expected to improve the learning effect of knowledge and technology obtained from lectures. We would like to make it a future subject in medical education to practice this effort in group encounters.

Acknowledgments
The authors would like to thank Dr. Heizo Tanaka, National Institute of Health and Nutrition, and Dr. Tetsuji Yokoyama, Tokyo Medical and Dental University, for their comments.

References
1. Allport, G. W. The Ego in Contemporary Psychology. Psychological review. 1943;451-479.

2. Artz, A. F. Cooperative Learning. Mathematics Teacher. 83, 1990; 448-449.

3. Billes, A. An index of adjustment and values. Journal of Counseling Psychology. 1971;15,257-261.

4. Block, Y. Ls satisfaction with self as a measure of adjustment. Journal of Abnormal and Social Psychology. l955;51,254-259.

5.Bruce, S. Using Cooperative to Enhance the Academic and Social Experience of Freshman Student Athlete. The Journal of Social Psychology. 1997;137:(4),449-459.

6.Cynthia, H. Cooperative Learning A Model for Teaching. Nursing Education. 1997;36(9)434-436,1997.

7.David, J. Cooperative Learning and Peer Acceptance of Student with Leaning Disabilities. The Journal of Social Psychology.1997;136:(6),741-752.

8. Dijon, T. Productive small groups in medical studies training for Cooperative learning. Medical Teacher. 1998;20(2),118-121.

9.Epstein, S. The Self-Concept revisited or a Theory. American Psychologist. 28.1973;404-416.

10.Nancy W, Effects of cooperative learning groups during Social Studies for students with autism and fourth grade peers. Journal of Applied Behavior Analysis, 1995;28, 175-188.

11.Rogers, C.R. Carl Rogers on Encounter Groups. Harper & ROW. 1997; The University of Chicago Press.

12.Rogers & Dymond. Psychotherapy &Personality Change. 1954; The University of Chicago Press.

13.Rogers, C.R. Counseling and psychotherapy. Boston, Naught on Mifflin Company. 1942.

14.Ross DD, Omar A, Pickens N, et al. Hospice and Palliative Care Education in Medical School a module on the role of the physician in end-of-life care. J Cancer Edu. 1997;12 (3):152-156.

15.Grater. H. Changes in self and others attitudes in a leadership training group. Personal Guiding Journal, 1957;37.493-496,

16.Billes. An index of adjustment and values. Journal of Counseling Psychology. 1971; 15,257-261.

17.Block. Ls satisfaction with self as a measure of adjustment. Journal of Abnormal and Social Psychology.1995; 51, 254-259.

18. Fenigstein, A. Self-Consciousness, self-attention, and interaction. Journal of Personality and Social Psychology. 1980; 37, 75-86.

19. Lipsitt, L. P. Child Development. 1958;29,463-472.

20.Rogers, C.R. Counseling and psychotherapy. Boston, Naught on Mifflin Company. 1952.

21.Tauber LE. Psychotherapy, encounter groups, and invasion of privacy.Ont Psychol. 1973 Oct;5(4):22-30.

22.Brown LK, Schultz JR, Parsons JT, Butler RB, Forsberg AD, Kocik SM, King G, Manco-Johnson M, Aledort L. Sexual behavior change among human immunodeficiency virus-infected adolescents with hemophilia. Adolescent Hemophilia Behavioral Intervention Evaluation Project Study Group.Pediatrics. 2000 Aug;106(2):E22.

23.Woods KF, Kutlar A, Johnson JA, Waller JL, Grigsby RK, Stachura ME, Rahn DW. Sickle cell telemedicine and standard clinical encounters: a comparison of patient satisfaction.Telemed J. 1999 Winter;5(4):349-56.

24.Eshel Y. Effects of in-group bias on planned encounters of Jewish and Arab youths.

J Soc Psychol. 1999 Dec;139(6):768-83.

25.Ratne M. A tale of two countries: promoting responsible sexual behaviour to improve reproductive health.Promot Educ. 1999 Jun;6(2):26-8, 41, 52.

26.Callahan EJ, Hilty DM, Nesbitt TS.Patient satisfaction with telemedicine consultation in primary care: comparison of ratings of medical and mental health applications.Telemed J. 1998 Winter;4(4):363-9.

27.Majumdar B, Keystone JS, Cuttress LA. Cultural sensitivity training among foreign medical graduates.Med Educ. 1999 Mar;33(3):177-84.

28: Thiederman S. Diversity training: facing the truth about pitfalls and benefits.

J Long Term Care Adm. 1997 Winter;24(4):37, 39.

29.Dollahon W. Diversity training sometimes causes more problems than it solves.

J Long Term Care Adm. 1997 Winter;24(4):36, 38.

30.Timms M, McHugh S, O'Carroll A, James T. Assessing impact of disability awareness training using the Attitudes Towards Disabled Persons Scale.Int J Rehabil Res. 1997 Sep;20(3):319-23.

31. Fleisher FI, White LJ, McMullen MJ, Chambers R. The geriatric obstacle course: a training session designed to help prehospital personnel recognize geriatric stereotypes and misconceptions.J Emerg Med. 1996 Jul-Aug;14(4):439-44.

32.Leonard PJ.Consciousness-raising groups as a multicultural awareness approach: an experience with counselor trainees.Cult Divers Ment Health. 1996;2(2):89-98.

33.Gans JS, Rutan JS, Wilcox N. T-groups (training groups) in psychiatric residency programs: facts and possible implications. Int J Group Psychother. 1995 Apr;45(2):169-83.

34.O'Donnell L, San Doval A, Duran R, O'Donnell CR. The effectiveness of video-based interventions in promoting condom acquisition among STD clinic patients.Sex Transm Dis. 1995 Mar-Apr;22(2):97-103.

35. Runia E, Nijenhuis E. "Experience-sharing" as an antidote to dependence-making behavior of general practitioners.Int J Group Psychother. 1995 Jan;45(1):17-35.

36.Carson RW. J Assoc Nurses AIDS Care. 1995 Jan-Feb;6(1):54-5.

37.Staff training sensitivity to the needs of elderly patients. Hosp Food Nutr Focus. 1994 Dec;11(4):suppl 1-2.

38. Orpen C.The effect of time-management training on employee attitudes and behavior: a field experiment. J Psychol. 1994 Jul;128(4):393-6.

39. Minton E. The Philadelphia story--a landmark case for EMS and the ADA.

J Emerg Med Serv JEMS. 1994 Jul;19(7):69-71.

40. Musham C, Brock CD. Family practice residents' perspectives on Balint group training: in-depth interviews with frequent and infrequent attenders.Fam Med. 1994 Jun;26(6):382-6.

41.Fahy ET. Transculturalism: still winking and speaking in code. Nurs Health Care. 1994 May;15(5):227.

42.Lum CK, Korenman SG. Cultural-sensitivity training in U.S. medical schools.

Acad Med. 1994 Mar;69(3):239-41.

43.Martin K, Wimberley D, O'Keefe K. Resolving conflict in a multicultural nursing department.Nurs Manage. 1994 Jan;25(1):49-51.

44.Diaz Barroso A. Balint groups: a personal experience. Aten Primaria. 1994 Jan;13(1):50.

45.Fernandez de Sanmamed M et al. The physician-patient relation through a Balint group.Aten Primaria. 1993 Oct 31;12(7):386-8, 390-2.

46. Butler R. Support groups address residents' personal development. J Am Osteopath Assoc. 1993 Jul;93(7):789-91.

47. Munich RL Varieties of learning in an experiential group.Int J Group Psychother. 1993 Jul;43(3):345-61.

48.Tizon JL. Reflection groups in primary health care. II. Some theoretical and technical elements.Aten Primaria. 1993 Apr 30;11(7):361-6.

49. Bogash ML, Quillen-Knox R. Training increases sensitivity to aging, resident needs. Provider. 1991 Dec;17(12):23-4.

50.Teschke DA. Employees experience effects of aging and learn. Healthc Financ Manage. 1991 Aug;45(8):101.

51. Estryn-Behar M. Encounter groups. Servir. 1990 May-Jun; 38(3):131-6.

52. Klar Y, et al. Characteristics of participants in a large group awareness training. J Consult Clin Psychol. 1990 Feb;58(1):99-108.

53.Taylor AJ. Grief counselling from the mortuary. N Z Med J. 1989 Oct 25;102(878):562-3.

54.Morath J. Empathy training: development of sensitivity and caring in hospitals. Nurs Manage. 1989 Mar;20(3):60-2.

55. Mao C, Bullock CS, Harway EC, Khalsa SK. A workshop on ethnic and cultural awareness for second-year students. J Med Educ. 1988 Aug;63(8):624-8.

56.Greenblatt F. Picture wall helps residents reminisce, sensitizes staff. Provider. 1988 Feb;14(2):28.

57. Kufferle B. Group dynamics as an emotional turmoil precipitating psychotic manifestations. Psychopathology. 1988;21(2-3):111-5.

58.Hawks IK. Facilitativeness in small groups: a process-oriented study using Lag Sequential Analysis. Psychol Rep. 1987 Dec;61(3):955-62.

59. Lloyd J. From differentiation to individuation: a look at the encounter process. Br J Sociol. 1987 Sep;38(3):351-72.

60.Lieberman MA. Effects of large group awareness training on participants' psychiatric status. Am J Psychiatry. 1987 Apr;144(4):460-4.

61. Siegel LI. Confrontation and support in group therapy in the residential treatment of severely disturbed adolescents. Adolescence. 1987 Fall;22(87):681-90.

62. Aveline M. The use of written reports in a brief group psychotherapy training. Int J Group Psychother. 1986 Jul;36(3):477-82.

63. Lundgren CC, Persechino EL.Cognitive group: a treatment program for head-injured adults. Am J Occup Ther. 1986 Jun;40(6):397-401.

64. Bale RN, et al. Three therapeutic communities. A prospective controlled study of narcotic addiction treatment: process and two-year follow-up results. Arch Gen Psychiatry. 1984 Feb;41(2):185-91.

65. Stravynski A, Shahar A. The treatment of social dysfunction in nonpsychotic outpatients. A review.J Nerv Ment Dis. 1983 Dec;171(12):721-8.

66.Rogers PL, Jacob H, Rashwan AS, Pinsky MR. Quantifying learning in medical students during a critical care medicine elective: a comparison of three evaluation instruments. Crit Care Med. 2001 Jun;29(6):1268-73.

67.Esfandiari A, Drew CR, Wilkerson L, Gill G, Drew CR. An international health tropical medicine elective. Ac ad Med. 2001 May;76(5):516.

68.Riley C, et alanaged care education in osteopathic medical schools: development of a fourth-year predoctoral healthcare management clerkship. J Am Osteopath Assoc. 2000 Nov;100(11):716-22.

69.Rogers PL, et al. Medical students can learn the basic application, analytic, evaluative, and psychomotor skills of critical care medicine. Crit Care Med. 2000 Feb;28(2):550-4.

70.Counselman FL, Griffey RT. Fourth-year elective recommendations for medical students interested in emergency medicine. Am J Emerg Med. 1999 Nov;17(7):745-6.

71.Sheps DM, Stern HS. The utility of the surgical clerkship elective. Can J Surg. 1998 Apr;41(2):168-9.

72.Barlev DM, Amis ES Jr. Termination of a mandatory radiology clerkship at the Albert Einstein College of Medicine: a survey of student opinion. Acad Radiol. 1994 Oct;1(2):187-90.

73.Rein MF, Randolph WJ, Short JG, Coolidge KG, Coates ML, Carey RM. Defining the cost of educating undergraduate medical students at the University of Virginia. Acad Med. 1997 Mar;72(3):218-27.

74. Mozaffarian D. An elective in tropical medicine: Eldoret, Kenya. Pharos Alpha Omega Alpha Honor Med Soc. 1997 Winter;60(1):27-31.

75. Wei Shet al. Innovative aspects of the 5th year BDS curriculum in Hong Kong. Int Dent J. 1996 Dec;46(6):531-5.

76.Chatenay M, et al. Does volume of clinical experience affect performance of clinical clerks on surgery exit examinations? Am J Surg. 1996 Oct;172(4):366-72.

77. Kern SJ, Filipi CJ, Gerhardt JD, Reeves MJ, Wright KM.A new concept for implementation of a required general surgery clerkship. Am J Surg. 1996 Sep;172(3):281-2.

78. Elnicki DM, Shumway JM, Halbritter KA, Morris DK. Interpretive and procedural skills of the internal medicine clerkship: performance and supervision. South Med J. 1996 Jun;89(6):603-8.

79. Fabri PJ, Powell DL, Cupps NB. Is there value in audition extramurals? Am J Surg. 1995 Mar;169(3):338-40.

80. Rogers PL, et al. Teaching medical students complex cognitive skills in the intensive care unit. Crit Care Med. 1995 Mar;23(3):575-81.

81. Foster EA. Long-term follow-up of an alternative medical curriculum. Acad Med. 1994 Jun;69(6):501-6.

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