A Teamwork Workshop to Improve Pharmacy Students’ Growth Mindset and Communication Skills

INTRODUCTION

Multidisciplinary health care teams are a complex social network that require collaboration and communication among the professionals that comprise the team in order to deliver effective and safe patient care.¹ Because ineffective collaboration can lead to errors and poor patient outcomes, teamwork among health care professionals is essential for successful high-quality care.² Doctor of Pharmacy (PharmD) graduates are expected to be team-ready clinicians with the Accreditation Council for Pharmacy Education Standards 2016 calling for pharmacy students to participate in team-based interprofessional learning experiences.³ Implementation of interprofessional education (IPE) in the first year of the PharmD program is an important phase in the preparation of team-ready professionals.⁴ A typical element of IPE is teaching students about the roles of other health care professionals through interprofessional student teams. However, outcomes from this type of early intervention are mixed.^5,6 Placing students together on a team may not necessarily result in the students aquiring improved teamwork skills. One possible explanation may be limited formal training for students on how to be a team member and how to develop interpersonal skills. This hypothesis is supported by surveys suggesting that new health professional graduates lack specific teamwork skills such as communication, conflict management, and team functioning.⁷

A common pedagogy used to teach teamwork in pharmacy education is having students work in groups for projects and team-based learning. Peer evaluation and peer feedback are often presented as reflective opportunities in which students can develop teamwork skills.⁸ However, in our experience, peer feedback is of limited value without a significant amount of explicit coaching and debriefing from faculty. Additionally, unresolved conflict between students can result in some students providing unexpected feedback to their peers well after the optimum time for coaching them regarding teamwork skills has passed. Furthermore, to make a lasting impact, students must then translate what they learned from these educational experiences during school to their future work on patient care teams.

In managing teamwork in the classroom, some students hold persistent beliefs that they must be on a “good” team to succeed or that they lack any control over their team’s effectiveness. The belief that “I must be on a good team to succeed” is defined by Dweck as a fixed self-view or fixed mindset.⁹ A fixed mindset is the belief that a person’s abilities and skills are unchangeable. Research suggests that fixed self-views undermine growth in the face of conflict.¹⁰ In contrast, learners with a growth mindset believe ability is not limited. Thriving team members may believe that “with hard work, I can succeed on any team.” Growth mindset learners seek challenges and remain effective during conflict.¹¹ Previous research involving PharmD students has demonstrated that a growth mindset is associated with the student having a favorable view of team learning.¹² However, changes in growth mindset over time and in the setting of team conflict lack study. Investigation into the relationship between students’ beliefs and growth on teams is needed to provide guidance for development of teamwork pedagogies.

Focused education on teamwork and conflict management delivered to students early in the pharmacy curriculum may impact team readiness. From this hypothesis, we developed a process-based approach to interpersonal relationships in the form of a pre-IPE intervention for first professional year (PY1) pharmacy students. We used a continuous professional development (CPD) framework for the teamwork workshop that emphasized personalized learning strategies to encourage lifelong learning.¹³ The StrengthsFinder survey was selected as a basis for individualization because of preliminary work done with pharmacy students using this tool.^14,15 StrengthsFinder allowed students a lens to understand their individual strengths that they have within themselves so that can use this personal information as a base going into teamwork. The goal is for students to understand their strengths so that they know what they can bring to a team. Growth mindset was promoted through situational teamwork training as trait identification alone may reinforce fixed mindsets. The learning goal of the teamwork workshop was to equip pharmacy students early with the fundamental interpersonal skills needed for conflict resolution. The objective of this study was to develop, implement, and assess the impact of a teamwork workshop on growth mindset and team communication using the validated Growth Mindset and Team Communication (GMTC) tool.¹⁶

METHODS

A multi-week workshop (five contact hours) for pharmacy students was created and incorporated into a required fall semester PY1 lecture course (Introduction to Pharmacy Practice) and laboratory course (Clinical Skills Lab I). An overview of the workshop’s timeline is provided in Figure 1. The multi-week series began during orientation with students learning about their personal traits by completing the StrengthsFinder 2.0 self-evaluation.¹⁵ During week 1 of the semester, the course coordinator collected the students’ results from the StrengthsFinder 2.0 in an Excel spreadsheet and used the stratified sampling allocation technique to divide students into groups which were maintained for all planned course activities. Heterogeneous groups were created by balancing students’ strengths according to the four StrengthsFinder domains¹⁵ as well as by taking into account their pharmacy work experience, educational experience, and student self-identification of certain traits, such as tendency towards being an introvert or extrovert.

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Figure 1.

Outline of Multi-week Teamwork and Conflict Management Workshop Components. Timeline Provided for Lecture and Laboratory Sessions Along with Pre- and Post-survey Administration.

During week 3 of the semester, the workshop continued with a classroom session on recognizing individual and team members’ strengths. This 80-minute interactive session focused on understanding personal strengths, professional teamwork relationships, and workplace needs and was led by a pharmacist. During week 4, students applied these concepts in the laboratory course where groups worked through two pharmacy team scenarios with a focus on diverse team member strength profiles. Student groups were tasked with identifying the characters’ primary strengths and workplace needs.

In week 7, the workshop continued in the didactic course where an 80-minute lecture provided students with tools to use when interacting in difficult team situations. Led by an expert in organizational communication, the session provided process-oriented communication models, including situational communication tools and group conflict resolutions models. The sessions for weeks 8 and 9 in the laboratory course were devoted to applying these tools to the two pharmacy scenarios that had been presented earlier in the semester. In the activity, student groups assessed elements of the conflict process, contributing factors, and team members’ workplace needs. Groups then wrote a conflict management note and narrative to suggest ways to resolve the conflict based on situational communication tools and group conflict resolution models. Student groups then acted out the narrative the following week in the next laboratory session. This was followed by a short debriefing conducted by a laboratory facilitator to engage students in conversation on the situational communication tools they selected for each scenario.

In addition, a longitudinal element for CPD was included throughout the semester.¹³ First, students were tasked with writing a personal statement that required them to reflect on their top five strengths as well as their educational and professional goals. Students completed a midpoint and final peer evaluation in which they ranked their peers on specific performance characteristics and provided written feedback on what they perceived as each team member’s top five strengths. The rubric used by students to evaluate each peer group member was developed by two of the authors modifying descriptors of professionalism defined by Hammer in 2000.¹⁷ The midpoint evaluation did not contribute to the students’ grades but served to identify potential areas of improvement. Each student’s final peer evaluation grade was calculated by averaging the scores from all of their peer evaluations and was worth 5% of the total course grade.

Students remained in their assigned groups for additional activities throughout the semester in the two linked classes, Introduction to Pharmacy Practice and Clinical Skills Lab I. Specifically, students completed approximately one low-stakes graded group activity in the lecture course each week and the group completed various laboratory activities for approximately two to three hours each week. Although these activities did not incorporate the described teamwork workshop components, the same student groups were maintained to ensure consistency in group learning. Beyond these two courses, students interacted with other students as part of different groups formed in other concurrent classes, depending on the structure and learning goals of the other classes.

RESULTS

Of the 74 students enrolled in fall 2017, 68 (91.9%) were included in the control group. Of the 116 students enrolled in fall 2018 and fall 2019, 106 (91.4%) were included in the intervention group. The demographics of the two cohorts were similar, except that more students in the intervention group self-identified as extroverts compared to the number in the control group (40.2% vs 22.5%).¹⁶

When the difference between the pre- and post-survey scale was compared between the intervention and control groups, the cumulative GMTC scale showed a large effect size (Cohen’s d of 0.94) between the groups. Based on the sum of the 14 growth mindset questions, the control group had a significant decrease in growth mindset between the pre- and post-survey vs the intervention group, which did not change significantly (Table 1). The standardized mean difference of an effect using the Cohen’s d formula yielded a large effect size of 0.83 for the Growth Mindset subscale between the groups. Based on the sum of the scores on the 13 team communication questions, the intervention group had a significantly greater increase in team communication than the control group, which did not experience a significant change in team communication (Table 2). The Team Communication subscale yielded a moderate effect size of 0.63 as determined by Cohen’s d. Overall, based on the sum of the five teamwork satisfaction questions, the intervention group had a significant increase in their satisfaction with teamwork experiences while the control group’s satisfaction with teamwork experiences did not change significantly (Table 3).

The top five Signature Themes from StrengthsFinder 2.0 were Achiever, Harmony, Restorative, Futuristic, and Responsibility. The dominant domain distribution was: Executing (n=23, 23.6%), Relationship (n=21, 19.8%), Strategic (n=11, 10.4%), Influencing (n=5, 4.7%), and No Dominant (n=44, 41.5%). For GMTC, the scores of students with Executing, Relationship, Strategic, and No Dominant as their dominant domains showed a trend toward improvement between the pre- and post-survey. This trend towards improvement was not seen in the scores of students whose dominant domain was Influencing (Figure 2).

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Figure 2.

Growth Mindset (2A) and Team Communication (2B) Score Trend in Relation to Dominant Domain Category for the Intervention Group. Of the 106 Participants, Students were Categorized into Each Dominant Domain Resulting in: Executing (n=23, 23.6%), Relationship (n=21, 19.8%), Strategic (n=11, 10.4%), Influencing (n=5, 4.7%), and No Dominant (n=44, 41.5%). Changes in Growth Mindset and Team Communication Between the Pre- and Post-Surveys are Shown.

A multiple linear regression to predict the difference in GMTC score based on gender, age, pharmacy-related work experience, number of Signature Themes belonging to each domain, and course grade did not result in any significant variable to predict the GMTC score.

Of the 68 students in the fall 2017 cohort, five (7.4%) volunteered to participate in the one-hour focus group, and 48 distinct comments from the session were included in our analysis. Of the 57 students in the fall 2018 cohort, three (5.3%) volunteered to participate in the focus group and 70 distinct comments were included in our analysis. Although which team a student had been on during the workshop was not considered when recruiting participants for the focus groups, the volunteers in each focus group included students from different teams with no participating students from the same group. Students’ attitudes expressed in the 118 total distinct comments were categorized as positive, mixed, or negative. These results revealed a difference between the control and intervention groups in that the responses of students in the intervention group were more balanced, with positive and mixed attitudes expressed, compared to the comments of students in the control group, which were generally more positive (Table 4). Corresponding action codes revealed that students found value in team communication and collaboration, noting that team experiences allowed them to share resources, learn from diverse perspectives, prepare for their future job/career, and build supportive relationships. These findings regarding students preparing for their future profession and building supportive relationships were similar between the control and intervention groups. However, the control and intervention groups diverged in sharing resources vs learning from diverse perspectives. The control group spoke more about shared resources while the intervention group’s discussion was more focused on learning from diverse perspectives. These differences extended to the content of students’ comments, with those in the control group valuing shared resources more for the purpose of collaborating to achieve a positive outcome vs those in the intervention group valuing the experience of learning from diverse perspectives, knowledge, or experience through the teamwork process (Table 4).

DISCUSSION

This study assessed the impact of a multi-week workshop on team communication for PharmD students using the validated GMTC tool. The intervention group showed a significant increase in both Growth Mindset (+0.7, p<.05) and Team Communication (+2.4, p<.05), suggesting the workshop had a positive impact on students’ attitudes related to teamwork. This is consistent with findings from a previous study by Hagemeier and colleagues which found that pharmacy students completing an interprofessional communication course resulted in improved students’ self-efficacy beliefs.²⁴ Although the quantitative increase in the subscale values was small, the effect size findings support that the workshop provided useful training for pharmacy students. Thus, early interventions aiming to improve pharmacy students’ self-awareness and self-evaluation skills in the context of direct instruction on team conflict models may be beneficial.

The GMTC tool captured data on two subscales: Growth Mindset and Team Communication. The growth mindset score showed a significant increase in the intervention group and a nonsignificant decrease in the control group. Overall, this resulted in a significant difference between the two groups showing again that the intervention may have contributed to a small improvement in growth mindset. This is the first study in pharmacy education to evaluate pre-post change in students’ growth mindset. In pharmacy students, the transition into a professional program with high expectations could result in a decrease in growth mindset. This study explored this critical transition to professional school in the first semester. Notably the magnitude of change was larger in the team communication subscale. The growth mindset subscale may be less sensitive and reactive to external intervention, while the team communication subscale may more directly capture changes from the educational intervention that encourages an integrative teamwork environment.

Within the team communication subscale, two reverse scored items had no change: “I feel uncomfortable taking the lead in a group” and “I prefer group work with clear performance and accountability standards.” Leadership and accountability skills were not emphasized in this workshop. Thus, this may represent a skill that could be emphasized in future iterations of the teamwork workshop. Clear performance and accountability standards is an interesting item because practice standards are increasingly common and may be essential to quality care. However, in other instances, standards may limit team growth, flexibility, and innovation. Accountability standards represent emerging professional teamwork concepts that were not discussed in this introductory teamwork workshop.

The qualitative results reflected overall positive views of team communication and collaboration, which was contextualized by discussions of advantages and challenges faced during the teamwork process and primarily positive outcomes. Comparison between the four action subthemes for the control and intervention groups suggest the intervention group may have benefited from the workshop. The control group’s positive evaluation included fewer comments related to process or collaborative solutions to teamwork challenges. In contrast, the intervention group demonstrated self-awareness, reflection on the process of teamwork, and openness to adapting and learning to overcome challenges. The intervention group resulted in more balance between positive and mixed attitudes as their comments suggested they were prepared, potentially by the intervention, to maximize the positive advantages and overcome negative challenges by managing the teamwork process to enhance learning, achieve positive outcomes, and prepare for the future through transferable teamwork and communication skills. The control group’s positive comments regarding actions may suggest less awareness and critique of the team process compared to the process assessment expressed by the intervention group which they attributed to the skills practiced and lessons learned during the intervention’s workshop series. Both the control and intervention groups discussed concern for collaborating within high-stakes assignments, which suggests that future inclusion of accountability standards content could help reinforce students’ responsibility in roles and tasks as the collaborative process is used in more difficult assignments.

The satisfaction with teamwork experiences as assessed by five questions in the survey provided a general positive view of teamwork experiences from the student perspective. Interestingly, both the control and intervention groups had many students in agreement with the question assessing contribution: “In most of the teams that I have been on, I generally contribute more than other team members.” This could represent a bias of overestimating one’s abilities and an opportunity to communicate expectations of group members in future groupwork. A major limitation of these survey questions is that the tool included general questions related to teamwork satisfaction without particular focus on this workshop or the assigned team used in these two particular classes. Thus, past experiences and current experiences on different teams may have impacted the results related to these specific questions.

Using the results from StrengthsFinder 2.0 for the intervention cohort, within each dominant domain category, the growth mindset subscale did not change before and after the intervention; however, the team communication subscale showed significant improvement in all dominant domains, except Influencing (Figure 2). According to Gallup’s CliftonStrengths assessment, people with Influencing dominant domain share expertise in communication by “taking charge, speaking up and making sure others are heard.”¹⁵ It is interesting to see that people who perceive themselves as “communicators” (ie, Influencing) may be less likely to have an impactful change in team communication subscale; however, this finding is limited by a small number of students with Influencing as their dominant domain. When compared with findings from the study conducted by Janke and colleagues, our pharmacy students had similar trends in Signature Themes compared to those found in pharmacy schools located in the Midwest.²¹

Limitations of this study include a single institution and a single-profession design. Although the single-professional design was planned so students could learn necessary teamwork skills before entering IPE experiences, it may be valuable to conduct early teamwork training among multiple health care disciplines. The study is also limited by a low participation rate and number of focus groups.²⁵Another limitation is the teamwork satisfaction questions which are not written in a way that focuses the questions on student perceptions for the specific team that was utilized in these two courses. Furthermore, this study assessed students’ views of their skills related to teamwork communication without including objective assessment of students’ skills by faculty. Although teamwork skills are difficult for faculty to evaluate when not present for individual team meetings, future work may consider objective measurements of individual students’ team communication skills.

An additional limitation is the nature of teamwork as a complex skill. Teamwork requires the development of interpersonal and conflict management skills which often takes years of experience to develop. Although this teamwork workshop and concurrent coursework provided students with the opportunity to spend a considerable amount of time working in their teams, there is always the possibility that teams were in different stages of team formation, and that this impacted the pre- and post-survey results in various ways. Additionally, the multi-week workshop held during one semester may not have been a sufficient amount of time for students to make lasting affective domain changes related to teamwork or growth mindset. Furthermore, an additional limitation is the difficulty in using a psychometric test, such as the GMTC, as there is not yet a threshold established in the literature defining the meaningful difference needed to demonstrate effect. The minimal clinically important difference (MCID) of GMTC score improvement of 6 points was calculated based on a large effect size of 0.8 using Cohen’s d formula. Both the growth mindset subscale and the team communication subscale were calculated to have an MCID of 3 points to reflect a large effect size. Our findings did not achieve score improvement greater than 6 points to meet the MCID, however future studies involving a larger sample size could be conducted to re-calculate the MCID. Nonetheless, based on the trend of improved teamwork communication, this study demonstrates that a teamwork workshop held early in the pharmacy curriculum has the potential to contribute to student learning of teamwork concepts. This exploration of early formative professional teamwork experiences and change over time expands our knowledge of strengths and teamwork across the pharmacy curriculum.^12,14

CONCLUSION

A teamwork workshop focused on maximizing strengths and resolving conflict resulted in a small improvement in first-year pharmacy students views of team communication abilities. An early workshop may provide pharmacy students with the necessary teamwork and conflict management skills needed for academic and professional success. Future work should focus on longitudinal measurement of pharmacy students’ self-views to determine the long-term impact of teamwork training interventions and if such interventions result in students’ success on future health care teams.