The effect of group-dynamics, collaboration and tutor style on the perception of profession-based stereotypes: a quasi-experimental pre- post-design on interdisciplinary tutorial groups

Background Group processes in inter-professional Problem-Based Learning (iPBL) groups have not yet been studied in the health-care educational context. In this paper we present findings on how group-dynamics, collaboration, and tutor style influence the perception of profession-based stereotypes of students collaborating in iPBL groups. Health-care students are trained in iPBL groups to increase their ability to collaborate with other healthcare professionals. Previous research focusing iPBL in healthcare implies that more systematic studies are desired, especially concerning the interaction between group processes and internalized professional stereotypes. The aim of this study is to investigate whether changes in group processes, collaboration, and tutor style, influence the perception of profession-based stereotypes of physician- and nursing-students. Methods The study is a quasi-experimental pre- post-design. The participants included 30 students from five different healthcare professions, mainly medicine and nursing. Other professions were physiotherapy, occupational therapy and speech therapy. The students were divided into four iPBL groups, each consisting of six to nine students and a tutor. Data were collected through systematic observation using four video-recorded tutorials. SPGR (Systematizing the Person Group Relation), a computer-supported method for direct and structured observation of behavior, was used to collect and analyze the data. Results Traditional stereotypical profession-based behaviors were identified in the first observed group meeting. Although the groups followed different paths of development, the group-dynamics changed in all groups over the 6 weeks of collaboration. Two of the groups became more cohesive, one became more fragmented and one became more polarized. Stereotypical behaviors became less frequent in all groups. Our findings indicate that tutor behavior has a strong influence on the development of the group’s dynamics. Conclusion Our findings strongly suggest iPBL is a means of reducing stereotypical behaviors, and may positively increase members’ ability to engage in inter-professional collaboration. Although the pattern of dynamics took different forms in different groups, we argue that iPBL forces students to see the colleague behind his or her profession, thus breaking professional boundaries. The tutor style significantly influenced the iPBL groups’ development. This study contributes to our field by emphasizing the effect of group-processes in increasing mutual understanding across professions.

tutor's role and behavior are best negotiated and developed through interactions with each tutorial group and must be adapted to the group's development and to the context (i.e. the task and group composition).
The aspects of group-dynamics [19,23] and leadership [5,11] in iPBL is highly understudied. Recent research emphasize that different contexts demand different dynamics for a group to be effective [39,40,41,42,42,44]. In spin theory [43,44] the construct balance is used to explain how group dynamics may change to suit contextual demands. In a stable context with simple tasks, a group may be effective with a xed role-structure and strong leadership, but with increased complexity and ambiguous tasks, a more exible role structure is needed. One would expect an iPBL group to develop a exible role-structure to be successful since the learning situation demands shared situational awareness and equal contributions from the group-members from/belonging to different health-care educations.
The operationalization of the spin-theory is labelled SPGR (Systematizing the Person Group Relation) and is a structured method for observing group behavior including algorithms for analyzing distribution of in uence, polarization, degree of opposition and other important aspects of group-dynamics. SPGR has been developed and re ned over the last forty years based on the observations of thousands of groups [29, 44, 45, 46, 47 48, 49]. The Norwegian Armed Forces have used SPGR in their training of military groups for more than twenty years.

Aim
The aim of this study was to investigate if changes in group processes, collaboration and if tutor style, in uence the perception of professional stereotypes of physician-and nurse-students. 1. Are professional stereotypes of physicians and nurses re ected in the students' initial behaviors in the iPBL groups?
2. Are there any changes in the dynamics of the iPBL groups over the six weeks of tutoring, and if so, in which way is the inter-professional stereotypes in uenced?
3. Does the tutor's behavior in uence the group's development and collaboration and, if so, how?

Design
The study is designed as a quasi-experimental pre-post study in which the groups are videotaped and observed at the start of the group sessions and at their nal meeting. Each tutorial group consisted of a tutor and a mixture of six to nine students of medicine and nursing and from other healthcare education such as physiotherapy, occupational therapy and speech therapy. All tutorial groups included in this study were natural groups in an authentic situation. We used direct observation to investigate the development of dynamics in four tutorial groups. We based our observations on video recordings of two group sessions separated by a six-week interval and used SPGR-software to directly observe group behavior to map and analyze our data using a validated category system [44,47].

Participants
The participants came from a cohort of 400 healthcare students at a large university in a medium-sized Swedish city during the second semester of their professional education. All students had at least one term experience of PBL and participated in the mandatory six-week course in interdisciplinary collaboration. A total of 35 people from four tutorial groups agreed to participate in this study. Thirty of the 35 were students (21 women and 9 men) between 19-40 years of age and ve were tutors (all female). All tutors were experienced tutors and had undergone compulsory college pedagogical tutorial group education.

Data Collection
The four tutorial groups were video recorded using three to four cameras in each session. The cameras were up and running before the session started. The researcher was not present in the room during the sessions. We observed the rst and the last sessions of each group. In each session, we observed a) the beginning, b) the choice of problem formulation (approximately the middle of the session) and c) session evaluation (the last activity). Thus, the observations spanned a period of time both between and within sessions, allowing us to get a fair picture of the development of behavior in the tutorial group. In total, this study builds on observations of four-hour video recordings.
The SPGR system for direct observations of group behavior In the SPGR system, behaviors supporting the four group functions are grouped in twelve categories (Table 1), [44,46,47]. Direct observation of groups using SPGR is supported by touchscreen-based software by which a trained observer registers a) which person acts and towards whom, b) what behavioral category best describes the act and c) whether the act was verbal or non-verbal. Hence, each registration included three decisions. Lively body language, inviting and con rming, seeking eye contact.
The four rst categories C, N, O and D cover behavior supporting the four basic group functions. Category W covers behavior that may lead to dissolution of the group and category S covers behavior that enhances collaboration.
The data are analyzed post-observation using SPGR algorithms which produce both statistics and the group's dynamic ( Fig. 1a, b-4a, b ). These analyses and diagrams let us evaluate the role structure by the position of each member in the social eld and the distribution of in uence in the group using the circle size of each person. Analysis of inter-rater reliability on a 10% sample of the data showed an acceptable level of agreement (69%). The study also has high face validity as both researchers involved in the registration subjectively and independently recognized the different tutorials when seeing the eld diagrams.

Results
There were four groups in this study, with a group size varying from six to nine students. All groups had three physicians and the number of nurses varied from one to three. The rest of the members came from other healthcare professions, such as physiotherapy, occupational therapy and speech therapy. Each group had a tutor. Over the six-week period, the activity of all four tutorial groups was dominated by taskoriented behavior, but their group-dynamics differed and their development over the observed period took different paths. Groups 1 and 3 (Figs. 1a, b and 3a, b ) became more cohesive, whilst Group 2 ( Fig. 2a, b) became more fragmented and Group 4 ( Fig. 4a, b) more polarized.
In Figs. 1a, b to 4 a, b, each person is mapped in SPGR eld diagrams. Each person is marked by a circle.
If the person shows mainly task-oriented behaviour, the circle is positioned in the upper sector of the diagram, mainly caring behavior in the lower right sector and mainly opposing behavior in the lower left sector. Larger circle sizes indicate dominant behavior. The left eld diagram represents observations from the rst group session and the right diagram from the last.

The First Tutorial Group Session
The predominant behavior of all members was task-oriented (located in the upper sector of the diagram).
The group was somewhat fragmented. Nur1b and Phy1b join in a subgroup toward the opposing sector (lower left). Phy1a and Tutor1 are the most dominant members (largest circle size), while Nur1a and Nur1b are the most submissive. The position of Phy1c and Tutor1, with balanced task-oriented and dominant behaviors, indicates that they played leading roles and were willing to support other group members. For example, when Nur1c had trouble starting an online contact group, Phy1c immediately presented his/her laptop and offered to help; Phy1c: "If you access this page... wait, I'll show you." This is in contrast with Nur1b's reaction when Nur1c was late for the session; Nur1b: "Showing up on time is important, isn't it?" and Nur1c's reaction: a gentle smile, downward gaze and closed body-language. Tutor1 mostly used non-verbal behaviors such as nodding and consistently looking at whoever was speaking, but, as her large circle indicates, this had a signi cant in uence on the group.

The Last Tutorial Group Session
During this session, the group displayed more cohesion, with all members contributing more equally (larger and equally sized circles) to the task. Phy1b has moved from opposition to show supportive behaviour, albeit in a submissive manner. Nurs1c had moved from being submissive to the most enthused. Tutor1 is not as much in charge and instead plays a highly supportive role.

Summary of the Tutorial Group's Development
Over the six weeks of interprofessional work, the tutorial group had evolved into a more cohesive group and the initial pattern of subgroups and fragmentation had dissipated. All the nurses acted according to their professional stereotypes; being fairly submissive in the rst session and more balanced and active in the last. The entire group moved slightly towards the lower right sector, representing more relationshiporiented behavior.
Tutorial Group 2 Tutorial group 2 consisted of one tutor (Tutor2) and eight students. Three physicians (Phy2a, Phy2b and Phy2c), two nurses (Nur2a and Nur2b) and three students from other healthcare professions. The averages of observed behavior for each person in the two sessions are presented in Fig. 2a, b.

The First Tutorial Group Session
Two members, Tutor2 and Phy2a, show strong task-orientation and dominance, polarized to the other members that are rather submissive (smaller circle sizes). Phy2c is the only one showing mostly relationoriented behavior and is the one farthest away from the group. All physicians showed behavior more dominant than the nurses and strongly in uenced the group's work, again according to their professional stereotypes. This is illustrated by an interaction during the meeting between Phy2a and Phy2c. After some back and forth discussion of when individual contributions should be delivered, Phy2a stated rmly "You who've got children, just upload your work when the children are in bed". Phy2c replied with a gentle smile: "We are just talking about one or two pages, not a thesis." When evaluating the group's work, Phy2c stated: "Some have worked more than others!" which was con rmed by another member: "Yes, it feels like we've let the others do the job for us." Tutor2 was rather authoritarian, for example when telling the group what to include in their texts: "There must be some facts in some way. But you do understand that it can't be 17 pages, it gets far too long." Interactions in the group are best described as fragmented, with several members appearing withdrawn and evasive.

The Last Tutorial Group Session
In this session, the group dynamic was quite different. Phy2a and Tutor2 still have dominating roles but are now accompanied by Nur2b and Phy2c. Phy2c's nurturing role in the rst session is now handled by two others in combination. Phy2b and especially Nur2a are now in opposition to the rest of the group, and the group is even more fragmented than in the rst session.

Summary of the Tutorial Group's Development
The fragmentation and tendency to polarization that were observed in the rst session emerged more clearly in the last session. Over the intervening six weeks, all members have become more active, but not more collaborative and two members (Phy2b and Nur2a) are now in opposition.

Tutorial Group 3
Tutorial group 3 (Fig. 3a ,b) comprised two tutors (one in the rst session and one in the last session) and six students: three physicians (Phy3a, Phy3b and Phy3c), two nurses (Nur3a and Nur3b) and one other healthcare profession. Their tutors are labeled Tutor3 in both cases The First Tutorial Group Session All members showed task-oriented but submissive behavior, except Tutor3 who was both dominant and demanding. For example, when Phy3a asked: "Should we decide on our topic now?" Tutor3 replied rmly: "No, we are still brainstorming!" instead of throwing the question back to the group to encourage them to re ect on their own process and collaboration. Group 3 may be labeled a "strong leader -follower" group. This is seen in Fig. 3a, b, which shows one large circle around Tutor3a, with the other members represented by small circles (submissive behavior).

The Last Tutorial Group Session
In this session, Phy3a and Phy3b played more leading roles and all members contributed more equally. For example, when the group talks about how the social service demands that healthcare should promote social participation and Phy3b says: "I think that 30 minutes with someone cooking for him [the patient] would make a difference in many ways." The members agree, followed by a series of suggestions on how healthcare could promote social participation. Although Tutor3 still showed rm and dominating leadership, the group had become more cohesive.

Summary of the Tutorial Group's Development
In the rst session, the group consisted of a strong leader, Tutor3, and followers. By the last session, the group had become more cohesive with more equally contributing members, even though Tutor3 remained authoritarian. Tutorial Group 4 Tutorial group 4 (Fig. 4a, b) consisted of a tutor (Tutor4) and nine students: three physicians (Phy4a, Phy4b and Phy4c), three nurses (Nur4a, Nur4b and Nur4c) and two other healthcare professionals.

The First Tutorial Group Session
Most members showed mostly task-oriented behavior. Tutor4, Phy4c and another member formed a leading coalition, while Phy4b and Nur4c show passive opposition. A subgroup of followers (Nur4a, Phy4a and Nur4b) was somewhat in opposition to the leading coalition, with Nur4a in a leading role (the largest circle). An example of submissive behavior occurred when Phy4a said to another student who was standing writing at the board, in a very quiet voice, that the message needed to be repeated. An example of passive opposition is Nur4c's constant checking of his/her mobile phone whilst the others were involved in discussion.

The Last Tutorial Group Session
In this session, a change of the group's dynamics was evident, with even stronger polarization between two more distinct sub-groups. One dominant and opposing sub-group (Nur4a, Phy4c, Tutor4 and another) versus a cohesive and submissive sub-group (Phy4a, Nur4b, Nur4c, Phy4b and one other), trying its best to be supportive and encouraging. A typical example of communication between the sub-groups occurred during the discussion of whether a patient with dementia should drive a car or be offered a travel service.
Phy4c: "We do not know enough; we only have his [the patient's] statement." Nur4a: "What should we do then?" Phy4c "There is a test with different scales that are recommended...".

Summary of the Tutorial Group's Development
During the six weeks, tutorial group 4 developed from a fragmented and somewhat polarized group to a strongly polarized group, with an opposing and dominant subgroup towards a cohesive and submissive sub-group committed to task-oriented collaboration. Tutor4 was part of the dominating sub-group in both sessions.

Discussion
There is a growing demand for iPBL to introduce interprofessional collaboration between pre-quali ed healthcare professions already at the educational stage [4,5,6] as a way to improve the safety and e cacy of patient care [12,24]. There seems to be an overall agreement on the e cacy of iPBL and that it fosters collaborative practice [ 4,5,20]. One large university in Sweden has adopted this approach, with students from different healthcare programs learning together in interprofessional tutorial groups [9,13,25] using PBL [2]. This raises questions of group processes and whether they are in uenced by physician and nurse professional stereotypes, not to mention the tutor's role over sessions in inter-professional tutorial groups in PBL. This study examined group processes and leadership in interprofessional tutorial groups, an under-investigated eld of research [2,5,19].

Four Tutorial Groups -Two Patterns of Group Development
The group dynamics in all four groups changed over the six weeks of collaboration, although following different paths. Two of the groups (group 1 and 3) became more cohesive with a higher quality of intragroup communication, whereas groups 2 and 4 became, accordingly, more fragmented and polarized [44,47], suggesting a reduced quality collaboration The distribution of in uence among group members is an important parameter of group dynamics. All groups showed a more equal distribution of in uence in the second session, and stereotypical behavior became less frequent. In these two aspects all groups improved, indicating that interprofessional collaboration took place [4,5,6,10,16]. Group 1 became more relationship-oriented by the last session, whilst the pattern of activity in group 2 remained unchanged.
Groups 3 and 4, on the other hand, becoming even more task oriented. Tutorial group 1 showed in addition less opposing behavior, while tutorial group 2 showed more opposition. Members of tutorial group 1 also increased their contribution over the six weeks period. Combined with a more equal distribution of in uence than the other groups, we can conclude that the developmental trajectory of this group was superior to those of the other three groups [44,47].

Stereotypical Behaviors
Three of the four tutorial groups showed more professionally stereotypical behaviors in the rst session than the last. In session 1, the physicians in groups 1, 2 and 4 dominate (18,30] and behave in a way that is consistent with physician stereotypes [29,32,33,34]. The nursing and other healthcare students all behaved submissively in the rst group session, consistent with the stereotypical role of nurses [15,17,20,21,50]. In the last group session, the physicians no longer dominated; the in uence of the other students had increased. One interpretation is that during the rst session, the physicians in groups 1, 2 and 4 presented a positive example that inspired collaboration and encouraged all group members to engage [ 11,15,29,50 ]. In addition, a few physicians were more submissive during the 6-week course. Tutorial group 3 showed a different pattern, as all the students were submissive in session 1. The tutor alone behaved exibly and dominated the group. In the last group session, however, almost all group members behaved more exibly, hence promoting bene cial collaboration.
Our results are in accordance with previous research showing that stereotypical professional behavior and preconceived notions about one's chosen profession and its allied professions are deep rooted and di cult to change [21,27,30,50]. Being locked into professionally stereotypical behavioral patterns may have a negative impact on interprofessional collaboration meaning that not all group members' competences are fully exploited [15,16,29,49]. Neither the development nor the performance of such groups is optimal. Our ndings suggest, however, that iPBL may loosen professional stereotypes (e.g. physicians become less dominant and nurses less submissive).
iPBL One of the premises of spin theory is that a well-functioning group should be able to adapt to different contexts and tasks [44,47]. This aligns well with iPBL, which is a student-centered, context-dependent approach to learning [3,13,19] a point further emphasized by Freeth et al. [5], hence, being a studentcentered, problem based self-directed learning context in which the interprofessional tutorial groups constitute learning collaboration, the utilization of all members' competences and contributions, problemsolving and re ection are natural components of the work of iPBL groups [9,11,19]. The students who participated in this study were used to PBL, but what was new to them was the interprofessional composition of the tutorial groups. One interpretation of the results is that the iPBL method played a role in the breaking down of professional roles and increasing of behavioral exibility during the six-week course. This is in line with previous research suggesting that iPBL is more naturally suited for increasing collaboration between pre-quali ed students from different healthcare specializations [4,5] but is something that needs further investigation.
The Effect of the Tutor's role on the Success of iPBL Even though we argue that iPBL is a good way of breaking down professional boundaries, it is clear that the effects are strongly in uenced by the tutor's role and behavior [2,3]. In all groups, the tutor was clearly active, dominating, directing and setting the agenda for the group's work. Whilst this may not, at rst sight, appear consistent with the principles of iPBL, it re ects the principle that tutors should facilitate the processes of the group rather than deliver content (11,19,35]. The chances of a successful group dynamic evolving are maximized if the tutor's role and behavior is negotiated and developed in interactions with members of the group and adapted to the context. In one group (tutorial group 1), the tutor showed signi cantly more mediating behavior than the tutors in the other three. This group followed the most positive developmental trajectory, becoming more cohesive and more self-managing, with members having more similar in uence in the last session than the rst. By the last session, the tutor had moved from a task-oriented role to a more supportive and caring one, which is consistent with a desirable development of the tutor's role in iPBL [3,19,36,37] In all the other groups, the tutor initially had a more directing and authoritarian facilitation style that endured and was still clearly evident in the last session.
None of the other groups were as successful as group 1, although group 3 had a fairly positive developmental trajectory. The members of group 3 were all rather submissive and although the group became more cohesive, the tutor's task-oriented behavior persisted. The difference between group 3 and groups 2 and 4 was that in the latter groups the authoritarian tutor was part of a dominant sub-group in session 1. We argue that this association is the main reason for the negative development of these two groups. Whilst we argue that iPBLis a good way of breaking down stereotypical behavior in groups, we also argue that the tutor's role is a vital factor in the success of the approach.

Limitations
The main limitations of this study are the small number of groups and that the analysis is based on observations of just four hours of video recording. Ideally, we would enlarge our study and include more groups "but that does not justify ignoring the information we could obtain" [51]. Using natural groups in an authentic situation affects the availability of participants. The level of inter-rater reliability (69%) might be considered a limitation but given that each registration was actually based on three decisions (who acts towards whom, category and verbal or non-verbal; see Method section), it can be considered good enough and correspond to what can be expected when each of the registrations actually corresponds to three decisions identical assessments. We argue that despite these limitations, the analysis of a small sample can lead to interesting insights.

Conclusion
The aim of this study was to investigate if changes in group processes, collaboration and if tutor style, in uence the perception of professional stereotypes of physician-and nurse-students. We found a clear pattern of behavior re ecting professional stereotypes of nurses and physicians in the initial group observation and that all four tutorial groups changed their group's dynamics over the six weeks of the course. Important elements of group-dynamics like distribution of in uence, polarization and opposition behavior changed, but the pattern of group-dynamics took different forms. Two of the groups became more cohesive, one more fragmented and one more polarized.
Our ndings suggest that stereotypical professional behaviors are already present among students of different health-related professions. Physicians' classically dominant position versus the more submissive approach associated with nurses were observed in the initial session of this study. However, in the last sessions, when groups had been working together for six weeks, stereotypic behaviors became less frequent. We argue that iPBL forces students to see the person behind the profession rather than the professional stereotype. An important aspect of iPBL is that all members must contribute equally for the problem to be solved.
Apart from observing fewer professional stereotypes in the second observation, we found that tutor's behavior strongly in uences group-development. The groups in which the tutor's role was consistent with the principles of PBL showed an improvement in group-dynamics and collaboration. Declarations