Prioritising the key behaviours that enhance the quality of collaborative learning by medical students: A modified Delphi study

Maha Iqbal, Gary M Velan, Anthony J O'Sullivan, Chinthaka Balasooriya


Introduction: Medical education has transitioned to require more active student learning, including self-directed and collaborative approaches. Although there are many advantages to collaborative small-group environments, learning in this setting is not always effective. One potential factor is that behaviours that are key to the success of small-group collaborative learning in medical education are yet to be clearly defined. In this study, we aimed to identify and prioritise behaviours that are relevant to individual students effective collaborative learning in small groups. 

Method: A two-round modified-Delphi approach was used to identify student behaviours that positively influenced the success of small-group collaborative-learning environments. In Round 1, the panel members were asked to rate the impact of 15 student behaviours on two subscales: (1) enhancing the quality of learning and (2) fostering a collaborative environment. The top 10 behaviours identified were utilised for Round 2, in which the panel members were asked to rank the behaviours based on the magnitude of their positive impact on students’ quality of learning. 

Results: Collaborative group behaviours were prioritised in Round 2, and the top six behaviours were selected for the design of a user-friendly educational intervention for medical students. The key behaviours identified were preparation by the student, involvement in discussion, engagement in learning, listening skills, sharing views and voicing opinions, reflecting on feedback and responding appropriately.

Conclusions: This study identified six key behaviours that influence students’ learning in small-group collaborative-learning environments. These findings will inform further research at our institution into the development and evaluation of an educational intervention that aims to foster the identified behaviours in medical students.


collaborative learning; Delphi technique; behaviours; group learning; small group teaching

Full Text:



Ajjawi, R., & Boud, D. (2015). Researching feedback dialogue: an interactional analysis approach. Assessment & Evaluation in Higher Education, 1-14. doi: 10.1080/02602938.2015.1102863

Australian Medical Council Limited. (2012). Accreditation Standards for Primary Medical Education Providers and their Program of Study and Graduate Outcome Statements. Australia.

Baeten, M., Dochy, F., Struyven, K., Parmentier, E., & Vanderbruggen, A. (2015). Student-centred learning environments: an investigation into student teachers’ instructional preferences and approaches to learning. Learning Environments Research, 19(1), 43-62. doi: 10.1007/s10984-015-9190-5

Balasooriya, C., Olupeliyawa, A., Iqbal, M., Lawley, C., Cohn, A., Ma, D., & Luu, Q. (2013). A student-led process to enhance the learning and teaching of teamwork skills in medicine. Education for Health, 26(2), 78-84. doi: 10.4103/1357-6283.120698

Bate, E., Hommes, J., Duvivier, R., & Taylor, D. C. M. (2014). Problem-based learning (PBL): Getting the most out of your students – Their roles and responsibilities: AMEE Guide No. 84. Medical Teacher, 36(1), 1-12. doi: doi:10.3109/0142159X.2014.848269

Beran, T. N., Kaba, A., Caird, J., & McLaughlin, K. (2014). The good and bad of group conformity: a call for a new programme of research in medical education. Medical Education, 48(9), 851-859. doi: 10.1111/medu.12510

Clancy, C. M., & Tornberg, D. N. (2007). TeamSTEPPS: Assuring optimal teamwork in clinical settings. American Journal of Medical Quality, 22(3), 214-217. doi: 10.1177/1062860607300616

Clayton, M. J. (1997). Delphi: a technique to harness expert opinion for critical decision‐making tasks in education. Educational Psychology, 17(4), 373-386.

Davidson, N., & Major, C. H. (2014). Boundary Crossings: Cooperative Learning, Collaborative Learning, and Problem-Based Learning. Journal on Excellence in College Teaching, 25(3 & 4), 7-55.

Davidson, N., Major, C. H., & Michaelsen, L. K. (2014). Small-Group Learning in Higher Education-Cooperative, Collaborative, Problem-Based, and Team-Based Learning: An Introduction by the Guest Editors. Journal on Excellence in College Teaching, 25(3 & 4 ), 1-6.

De Grave, W. S., Dolmans, D. H., & Van Der Vleuten, C. P. (2002). Student perspectives on critical incidents in the tutorial group. Adv Health Sci Educ Theory Pract, 7(3), 201-209.

De Villiers, M. R., De Villiers, P. J., & Kent, A. P. (2005). The Delphi technique in health sciences education research. Medical Teacher, 27(7), 639-643.

Dolmans, D. H., Loyens, S. M., Marcq, H., & Gijbels, D. (2015). Deep and surface learning in problem-based learning: a review of the literature. Advances in Health Sciences Education, 21(5), 1087-1112.

Dolmans, D. H. J. M., & Schmidt, H. G. (2006). What do we know about cognitive and motivational effects of small group tutorials in problem-based learning? Advances in Health Sciences Education, 11(4), 321-336.

Dolmans, D. H. J. M., Wolfhagen, I. H. A. P., & Van Der Vleuten, C. P. M. (1998). Motivational and cognitive processes influencing tutorial groups. Academic Medicine, 73(10 SUPPL.), S22-S24.

Frank, J. R., Snell, L. S., & Sherbino, J. (2014). The Draft CanMEDS 2015 Milestones guide: Royal College of Physicians and Surgeons of Canada.

General Medical Council. (2015). Tomorrow's doctors: Outcomes for undergraduate medical education: General Medical Council London.

Gordon, M., Baker, P., Catchpole, K., Darbyshire, D., & Schocken, D. (2014). Devising a consensus definition and framework for non-technical skills in healthcare to support educational design: A modified Delphi study. Medical Teacher, 37(6), 572-577. doi: 10.3109/0142159X.2014.959910

Haider, S. I., Johnson, N., Thistlethwaite, J. E., Fagan, G., & Bari, M. F. (2014). WATCH: Warwick Assessment insTrument for Clinical teacHing: Development and testing. Medical Teacher, 37(3), 289-295. doi: doi: 10.3109/0142159X.2014.947936

Hartling, L., Spooner, C., Tjosvold, L., & Oswald, A. (2010). Problem-based learning in pre-clinical medical education: 22 years of outcome research. Med Teach, 32(1), 28-35.

Hasson, F., Keeney, S., & McKenna, H. (2000). Research guidelines for the Delphi survey technique. Journal of Advanced Nursing, 32(4), 1008-1015.

Hayward, M. F., Curran, V., Curtis, B., Schulz, H., & Murphy, S. (2014). Reliability of the Interprofessional Collaborator Assessment Rubric (ICAR) in Multi Source Feedback (MSF) with Post-Graduate Medical Residents. BMC Medical Education, 14(1), 1049.

Hmelo, C. E., & Eberbach, C. (2012). Learning Theories and Problem Based Learning. In S. Bridges, C. McGrath & T. L. Whitehill (Eds.), Problem-Based Learning in Clinical Education (Vol. 8, pp. 8-17).

Iqbal, M., Velan, G. M., O’Sullivan, A. J., & Balasooriya, C. (2016). Differential impact of student behaviours on group interaction and collaborative learning: medical students’ and tutors’ perspectives. BMC Medical Education, 16(1), 217. doi: 10.1186/s12909-016-0730-1

Johnson, D. W., & Johnson, R. T. (2002). Learning together and alone: Overview and meta‐analysis. Asia Pacific Journal of Education, 22(1), 95-105.

Jones, J., & Hunter, D. (1995). Consensus methods for medical and health services research. BMJ: British Medical Journal, 311(7001), 376.

Kaufman, D. M., & Mann, K. V. (2014). Teaching and learning in medical education: How theory can inform practice. In e. T. Swanwick (Ed.), Understanding Medical Education: Evidence, Theory and Practice (Vol. 5, pp. 57-60). Oxford, UK.: John Wiley & Sons, Ltd.

Kelly, M., Bennett, D., Muijtjens, A., O’Flynn, S., & Dornan, T. (2015). Can less be more? Comparison of an 8-item placement quality measure with the 50-item Dundee Ready Educational Environment Measure (DREEM). Advances in Health Sciences Education, 20(4), 1027-1032.

Kilgour, J. M., Grundy, L., & Monrouxe, L. V. (2016). A Rapid Review of the Factors Affecting Healthcare Students' Satisfaction with Small-Group, Active Learning Methods. Teaching and Learning in Medicine, 28(1), 15-25. doi: 10.1080/10401334.2015.1107484

Koh, G. C.-H., Khoo, H. E., Wong, M. L., & Koh, D. (2008). The effects of problem-based learning during medical school on physician competency: a systematic review. Canadian Medical Association Journal, 178(1), 34-41. doi: 10.1503/cmaj.070565

Kropiunigg, U. (2002). Teamshaping in medical teaching: Changing groups to teams. Medical Teacher, 24(6), 649-651. doi:

Kropiunigg, U., Pucher, I., & Weckenmann, M. (2002). Learning in groups: Teamshaping in the teaching of medical psychology. Medical Education, 36(4), 334-336. doi:

Liaison Committe on Medical Education. (2011). Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. USA.

Miller, G. A. (1956). The magical number seven, plus or minus two: some limits on our capacity for processing information. Psychological review, 63(2), 81-97. doi: 10.1037/h0043158

Morrison, G., Goldfarb, S., Lanken, P., Morrison, G., Goldfarb, S., & Lanken, P. (2010). Team Training of Medical Students in the 21st Century: Would Flexner Approve? Acad. Med., 85(2), 254-259. doi: 10.1097/ACM.0b013e3181c8845e

Mpofu, J., Das, M., Stewart, T., Dunn, E., & Schmidt, H. (1998). Perceptions of group dynamics in problem-based learning sessions: a time to reflect on group issues. Medical Teacher, 20(5), 421-427.

Norman, G. R., & Schmidt, H. G. (1992). The psychological basis of problem-based learning: a review of the evidence. Acad Med, 67(9), 557-565.

Olupeliyawa, A., O’Sullivan, A., Hughes, C., & Balasooriya, C. (2014). The Teamwork Mini-Clinical Evaluation Exercise (T-MEX): A Workplace-Based Assessment Focusing on Collaborative Competencies in Health Care. Academic Medicine, 89(2), 359-365 310.1097/ACM.0000000000000115.

Parmelee, D., Michaelsen, L. K., Cook, S., & Hudes, P. D. (2012). Team-based learning: A practical guide: AMEE Guide No. 65. Medical Teacher, 34(5), e275-e287.

Pervaz Iqbal, M., Balasooriya, C., O'Sullivan, A., & Velan, G. (2014). Identifying the critical and important collaborative competencies that relate to effective collaborative learning environments in medicine. Paper presented at the ANZAHPE Gold Cost.

Polit, D. F., & Beck, C. T. (2006). The content validity index: are you sure you know what's being reported? Critique and recommendations. Research in Nursing & Health, 29(5), 489-497.

Polit, D. F., Beck, C. T., & Owen, S. V. (2007). Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Research in Nursing & Health, 30(4), 459-467.

Polyzois, I., Claffey, N., & Mattheos, N. (2010). Problem-based learning in academic health education. A systematic literature review. European Journal of Dental Education, 14(1), 55-64.

Rowe, G., & Wright, G. (1999). The Delphi technique as a forecasting tool: issues and analysis. International journal of forecasting, 15(4), 353-375.

Sandars, J. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher, 31(8), 685-695.

Schmidt, H. G., Van Der Molen, H. T., Te Winkel, W. W. R., & Wijnen, W. H. F. W. (2009). Constructivist, Problem-Based Learning Does Work: A Meta-Analysis of Curricular Comparisons Involving a Single Medical School. Educational Psychologist, 44(4), 227-249. doi: 10.1080/00461520903213592

Schönrock-Adema, J., Visscher, M., Raat, A. J., & Brand, P. L. (2015). Development and Validation of the Scan of Postgraduate Educational Environment Domains (SPEED): A Brief Instrument to Assess the Educational Environment in Postgraduate Medical Education. PLoS ONE, 10(9), e0137872.

Shehnaz, S. I., Premadasa, G., Arifulla, M., Sreedharan, J., & Gomathi, K. G. (2015). Development and validation of the AMEET inventory: An instrument measuring medical faculty members' perceptions of their educational environment. Medical Teacher, 37(7), 660-669.

Skinner, V. J., Braunack-Mayer, A., & Winning, T. A. (2015). The Purpose and Value for Students of PBL Groups for Learning. Interdisciplinary Journal of Problem-based Learning, 9(1), 7.

Slavin, R. E. (1996). Research on Cooperative Learning and Achievement: What We Know, What We Need to Know. Contemporary Educational Psychology, 21(1), 43-69. doi:

Sobral, D. T. (1998). Productive small groups in medical studies: Training for cooperative learning. Medical Teacher, 20(2), 118-121. doi:

Sunderji, N., & Waddell, A. (2015). Using real-time Delphi to develop a consensus on competencies. Medical Education, 49(11), 1151-1152. doi: 10.1111/medu.12851

Survey Monkey. (2014). Ranking question Retrieved October, 2014, 2014, from

Tan, C. P., & Tan, N.-H. (2006). A simple instrument for the assessment of student performance in problem-based learning tutorials. Annals of the Academy of Medicine, Singapore, 35, 634-641.

Tavares, W., Ginsburg, S., & Eva, K. W. (2016). Selecting and Simplifying: Rater Performance and Behavior When Considering Multiple Competencies. Teaching and Learning in Medicine, 28(1), 41-51. doi: 10.1080/10401334.2015.1107489

Tipping, J., Freeman, R. F., & Rachlis, A. R. (1995). Using faculty and student perceptions of group dynamics to develop recommendations for PBL training. Academic Medicine, 70(11), 1050-1052.

van Blankenstein, F. M., Dolmans, D. H., van der Vleuten, C. P., & Schmidt, H. G. (2011). Which cognitive processes support learning during small-group discussion? The role of providing explanations and listening to others. Instructional Science, 39(2), 189-204.

Visschers-Pleijers, A. J. S. F., Dolmans, D. H. J. M., de Grave, W. S., Wolfhagen, I. H. A. P., Jacobs, J. A., & van der Vleuten, C. P. M. (2006b). Student perceptions about the characteristics of an effective discussion during the reporting phase in problem-based learning. Medical Education, 40(9), 924-931.

Visschers-Pleijers, A. J. S. F., Dolmans, D. H. J. M., De Leng, B. A., Wolfhagen, I. H. A. P., & Van Der Vleuten, C. P. M. (2006a). Analysis of verbal interactions in tutorial groups: A process study. Medical Education, 40(2), 129-137. doi: 10.1111/j.1365-2929.2005.02368.x

Visschers-Pleijers, A. J. S. F., Dolmans, D. H. J. M., Wolfhagen, I. H. A. P., & Van Der Vleuten, C. P. M. (2004). Exploration of a method to analyze group interactions in problem-based learning. Medical Teacher, 26(5), 471-478.

Visschers-Pleijers, A. J. S. F., Dolmans, D. H. J. M., Wolfhagen, I. H. A. P., & Van Der Vleuten, C. P. M. (2005b). Student perspectives on learning-oriented interactions in the tutorial group. Advances in Health Sciences Education, 10(1), 23-35. doi: 10.1007/s10459-004-9348-x

Wallace, M. L., Walker, J. D., Braseby, A. M., & Sweet, M. S. (2014). " Now, What Happens During Class?" Using Team-Based Learning to Optimize the Role of Expertise Within the Flipped Classroom. Journal on Excellence in College Teaching, 25.

Webb, N. M. (2013). Information processing approaches to collaborative learning. In C. E. Hmelo, C. A. Chinn, C. Chan & A. M. O'Donnell (Eds.), The International Handbook of Collaborative Learning. New York: Taylor and Fancis.

Weidman, J., & Baker, K. (2015). The Cognitive Science of Learning: Concepts and Strategies for the Educator and Learner. Anesthesia & Analgesia, 121(6), 1586-1599. doi: 10.1213/ane.0000000000000890

Young, J. Q., Van Merrienboer, J., Durning, S., & Ten Cate, O. (2014). Cognitive load theory: Implications for medical education: AMEE guide no. 86. Medical Teacher, 36(5), 371-384.



  • There are currently no refbacks.