The challenge of understanding , evaluating and providing feedback on regulation during group learning

Received on: Oct.02sd, 2020. Approved on: Feb. 15th, 2021. Abstract: Learning in groups is commonly used in academic and clinical health professions education (HPE). There is growing recognition that regulation during learning is essential for both the individual learner and group learning. The authors in this article propose a practical approach for understanding, evaluating and providing feedback on regulation during group learning. The approach is informed by previous studies conducted in other areas of education. Three varieties of regulation during group learning are discussed: individual, co-regulation and shared regulation. Each variety of regulation has a focus on three essential activities during group learning: task, social and motivation. Illustrative scenarios are presented to describe how the approach can be practically used in HPE. The specific and additional focus on regulation can enhance current approaches for providing feedback on group learning and the authors discuss recommendations for practical implementation and future research.


Introduction
Learning in groups, which we will refer to as group learning throughout the article, has been commonly used across the continuum of health based learning in academic situations (2) and also simulation training (3) and inter-professional team training in clinical situations (4). In all of these situations, group learning is both a process and an outcome (5) The essential characteristic is the interaction of two or more individuals, with the acquisition of new knowledge, skills, experiences, and perspectives from others in the group (5).
Research on the outcome of group learning shows increased new knowledge and understanding compared with learning alone (5,6). In addition, there is development of important social skills that are essential for future group learning and working together, including problem solving and positive interdependence with acceptance of diversity and negotiation of differences in opinion (6 -8).
There is the potential that the new knowledge and social skills that have been acquired during group learning can also be applied to future healthcare, especially when there is an increasing emphasis on learning and working together in inter-professional groups (9,10).
A challenge for all HPE educators interested in improving the effectiveness of group learning is to understand and evaluate the process that occurs during learning so that it can inform developmental feedback to increase the effectiveness of group learning (5). There has been increasing interest in HPE about understanding regulation during both academic and clinical learning situations (11), with a focus on how learners are actively engaged in managing their learning by using an adaptive process to optimize their learning (12). This interest in regulation during learning in HPE has almost exclusively been on the individual learner but recently there has been increasing recognition of the importance of regulation during group learning in both academic and clinical situations (13,14).

Understanding regulation during learning
There are several models that describe regulation during learning by individuals, which is often called self-regulation (12). Optimizing learning during different learning situations, such as exploring the causes of heart failure or how to insert a venous cannula, requires an active and cyclical metacognitive adaptive process of the essential cognitive and motivational aspects of learning, which also includes the important emotional factors that can influence motivation (19,20).
A feature of all models of regulation during learning is the description of several phases but there are slight differences in the nomenclature and number of phases. A three-phase model of planning, monitoring and adaptive change is presented and is based on a commonly used model (19).

Before learning
The individual initially evaluates the demands of the learning situation, including the expected cognitive and motivational demands, and develops a plan to achieve learning. This plan includes setting a goal, which is the expected outcome of the learning, and the selection of an appropriate strategy and specific techniques to attain the goal. The focus of the planning may be on cognitive task-related activities, such

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as selecting a problem-solving model for an academic task or a specific procedural technique for a clinical skill. The focus of the plan may also be on motivational-related activities, such as controlling anxiety or enhancing self-efficacy beliefs by recalling previous successful, or unsuccessful, learning.

During learning
The individual monitors the extent to which their chosen cognitive and motivational strategy and techniques are being optimised to attain the intended goal. In response to monitoring, the individual can make adaptive changes to their chosen cognitive and motivational goals, strategies, and techniques in an attempt to optimally attain the intended goal.

After learning
This is the opportunity for the individual to reflect on how they have approached the learning situation and to consider the need to modify their future planning before learning. Feedback from another individual, such as learner or an educator, can have important additional benefits, including evaluation and feedback from a different perspective (15).
Research has highlighted the importance of each phase informing the next as an integrated cyclical process, with monitoring and making adaptive changes during learning being considered as essential to ensure that the cognitive and motivational aspects of learning can be optimal for the situation (20).

Understanding regulation during group learning
Several studies from other areas of education have provided greater understanding of regulation during group learning, especially in computer supported collaborative groups and learning groups in young children (21,22). This research has consistently identified three core varieties of regulation during group learning: (a) Individual regulation: An individual only regulates their own learning (22).
(b) Co-regulation: An individual provides and/or receives regulation by social interaction between one or more other learners (23).
(c) Shared regulation: The regulation of learning occurs between all learners and is collectively shared between these learners (24).
Within each variety of regulation, three core learning activities have been identified and each activity must be regulated by planning, monitoring and adaptive change to optimise learning (25): (a) Task-related activities: These activities have a focus on the knowledge that is required to learn in the situation, including clarification of the goal and choosing a strategy or technique, such as using a mnemonic to structure new information or an airway management approach in a simulated unconscious patient.
(b) Social-related activities: These activities have a focus on the social interactions between the learners that are required to learn in the situation, such as the allocation of roles and responsibilities.
(c) Motivation-related activities: These activities have a focus on the essential motivational support that is required to learn in the situation, such enhancing self-efficacy beliefs or reducing anxiety.
Our practical approach for understanding regulation during group learning in HPE is also based on three core varieties of regulation and the three core learning activities that have been identified in other areas of education. This is summarised in Table 1. Knowledge and skills provided and /or received between one or more learners to optimise learning.

Knowledge and skills
shared between all learners to optimise learning.

Social-related
No social interactions by the individual learner required to optimise learning.
Social interactions provided and / or received between one or more learners to optimise learning.
Social interactions shared between all learners to optimise learning.

Motivationrelated
Motivation applied by only one learner to optimise learning.
Motivation provided and /or received between one or more learners to optimise learning.
Motivation shared between all learners to optimise learning.
Regulation during group learning is complex since individual regulation, co-regulation and shared regulation are occurring simultaneously (26). Each individual learner has to continually regulate their own learning to optimize learning but sometimes an individual requires additional regulation support from other learners in the group (26). This support occurs as short and transitory episodes in which co-regulation occurs between only one or two learners, either when a learner requests additional support or when a learner recognises that another learner requires additional support (26). Research suggests that shared regulation between all learners is associated with maximum learning for each learner in the group (21,26). However, shared regulation may require additional support, especially at the beginning of a learning situation and also at critical moments during the situation when the group is faced with evolving increased demands. At these times, transitory episodes of co-regulation can act as a 'kick-start' to initiate shared regulation (26).

(a) Structured interviews
A structured interview provides a useful method for identifying an individual's perspective of both their own regulation but also their contribution to regulation of the whole group. However, like all selfreport tools, interviews can be prone to inaccurate responses related to recall and social desirability biases (28). Questions can explore an individual's self-regulation and their intention to begin coregulation to optimize their own learning, but also about the reasons for not putting their intention to provide or receive co-regulation into action. An illustrative example is provided in Scenario 1.

Scenario 1:
Greg, a first year student, complained to his group facilitator that he was "not learning anything" in his problem-based learning group.

Scenario 2:
The group is expected to work as a team to implement an advanced life support protocol whilst managing a simulated cardiac arrest situation. The facilitator noticed that the group had initially nominated a team leader but then the group appeared to struggle with the two- An illustrative example is provided in Scenario 3.

Scenario 3:
The facilitator of a problem-based learning group is aware that the group of first year students had a moment when they were struggling during the discussion of a case of a patient with jaundice.

Feedback on regulation during group learning
Feedback after learning promotes reflection to stimulate future change in learning behaviour but it is essential that it is relevant to the learner, with a specific focus on the evaluation of appropriate, and not so appropriate, behaviours (31) This finding would be important for feedback to the group so that learners can recognise these times and respond with shared regulation, which is essential for effective group learning (26).
The intention of the practical approach described in this article is on regulation but for feedback to be most effective it is likely to also require the inclusion of strategies and specific techniques within the three core learning activities (16). This approach to providing 'regulation enhanced' feedback, which includes both regulation and strategies and techniques, has been described for providing feedback on self-regulation of individual learning (35), but it uncertain whether this can also be applied to group learning. Similar to the provision of feedback for other learning, it is also important that the educator creates a supportive environment and to actively involve the participants in identifying aspects that require further development (36).

Future directions on understanding, evaluating and feedback on regulation during group learning
Our proposed practical approach is the first in HPE for understanding and evaluating regulation during group learning, with an intention to provide feedback on the essential regulation during group learning.
An essential direction for further research and development is on how the approach can be implemented in practice. An initial priority is to develop and assess the evaluation methods.
Templates for structured interviews and videoobservation will need to be valid and reliable, especially for identifying the complexity of the changing sequences of co-regulation and shared regulation during group learning (37). This research will require inter-rater reliability studies and the iterative development of the evaluation methods in partnership with the intended users to ensure that the methods are 'fit for purpose'. The next priority is conducting feasibility and development research to ensure that educators can easily integrate the new approach into their usual debriefing and feedback practice but also that learners perceive that the feedback on regulation during group learning is useful to inform their future learning. We also recommend that this research is in partnership with the intended users. Finally, effectiveness studies of the impact of feedback on subsequent group learning can be conducted when appropriate evaluation methods and a practical approach for evaluation and feedback has been developed. An exciting area for future research is also whether feedback on regulation during group learning can have an impact on group learning situations and working together in healthcare.
We have also identified an important area for future research that has a focus on understanding the importance of times during group learning when co-regulation is most appropriate and also the factors that enable and constrain its use. Research could explore who takes responsibility to co-regulate other individuals in the group and also the factors that influence if co-regulation initiates a shift to shared regulation of learning. This has implications for providing feedback at times of critical importance when in similar learning situations.

Conclusion
Developing group learning in HPE requires increased attention on providing effective feedback that has a specific focus on developing the essential regulation during group learning.
Our proposed practical approach provides an opportunity to increase understanding of regulation during group learning so that this understanding can inform evaluation and feedback after learning. We consider that specific feedback on regulation during group learning can enhance current approaches that are used for providing feedback on group learning in HPE.

Conflicts of interest disclosure
The authors declare no competing interests relevant to the content of this study.