Evaluating Team-Based Learning in a Transnational Post Registration Bachelor of Nursing Program in Singapore

doi:10.21203/rs.3.rs-287237/v1

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Evaluating Team-Based Learning in a Transnational Post Registration Bachelor of Nursing Program in Singapore

https://doi.org/10.21203/rs.3.rs-287237/v1

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Background: Team-Based Learning (TBL) is growing in popularity as a method to create active learning within larger group lectures. It is facilitated through phases of individual work, teamwork and immediate feedback, to develop students’ understanding and assessment of conceptual knowledge. A single facilitator can manage many groups within larger lectures. The study aim was to evaluate the impact of TBL on the engagement, learning and satisfaction of students enrolled in a transnational post registration Bachelor of Nursing (BN) program in Singapore.

Methods: A cross-sectional design was employed. The TBL approach was delivered during lecture sessions within a post registration BN program delivered in a Higher Education Institution in Singapore. A sample of BN students was drawn from 305 students undertaking the program. Participation in the surveys was voluntary with informed consent protocols followed. An online anonymous university-delivered student evaluation of course (SEC) survey and an online anonymous survey using the Student Assessment Instrument, were used to collect quantitative and qualitative data. Student performance in the course was also reviewed.

Results: Eighty-two students (27%) completed the SEC scoring a median of 4/5 for satisfaction, and 68 (22%) completed the online survey. As 93 was the neutral score for the survey, there was a moderately positive evaluation with an overall score of 108.5/155 for TBL in accountability for learning, TBL preference and satisfaction with TBL compared to traditional lecture approaches.

Conclusions: Implementation of TBL with this cohort demonstrated evidence of moderately positive engagement, learning and satisfaction when compared to traditional didactic lectures.

Nursing

Team-Based Learning

Transnational Education

Active Learning

Nursing Students

Many East Asian students accessing Higher Education experience didactic teaching methods [1]. Some Asian cultures foster an atmosphere of passive learning, respectful deference to the authority of the teacher and/or text, and consequently students become accustomed to situations where they are attentive to the speaker in structured, managed, environments. This can lead to a reluctance to critique or question in group or collaborative situations [2]. However, such students have also demonstrated adaptability to other instructional approaches and can gain deeper learning with appropriate exposure [3;4]. Team-Based Learning (TBL) is an active learning approach that is growing in popularity and is increasingly utilised as a teaching approach in medical and other health professional education programs [5;6;7].

This paper discusses the implementation and evaluation of TBL within a transnational Bachelor of Nursing (BN) post-registration program for Singaporean nurses. In this context, TBL was implemented to replace large-scale didactic lectures previously delivered within the program.

As a result of the COVID-19 pandemic, higher education institutions have been crucially affected, and there is a need to ensure economic viability of institutions, which includes increasing numbers of fee-paying students whilst attempting to maintain quality [8]. Viability and maintaining quality are not new phenomena, but due to the pandemic, it is an increasingly prevalent dilemma. It has been highlighted that economic and demographic trends are impacting higher education institutions, and many seek to minimise inefficiencies and maximise revenue by increasing student numbers [9]. These factors inevitably lead to growing class sizes and a reliance on lectures as a method to impart course information [10].

However, a systematic review and meta-analysis of 225 studies involving over 29,000 science, technology, engineering and mathematics students demonstrated that active learning approaches reduced fail rates by 55% and improved grades by up to half a grade band when compared to didactic teaching methods [11]. Despite these findings, a study [12] that surveyed nurse educators found that only around 5% of them did not use lectures at all, and some educators stated that lectures were used by them up to 75% of the time, suggesting that although active learning is utilised, large-scale lectures are still prevalent.

Team-Based Learning is growing in popularity as an approach to providing active learning within large class settings. For example, in a systematic review [13] it was noted that from 2011–2016, there were 87 TBL studies involving health professionals alone; over triple the number from the previous five years. Team-Based Learning involves small group instructional approaches facilitated through structured phases of individual work, teamwork and immediate feedback, to develop students’ understanding and assessment of conceptual knowledge [14]. Because of the structured nature of the approach, a single facilitator can manage many groups within larger lecture type settings, requiring fewer resources and creating advantages over other types of small group active learning methods [15].

Studies have shown favourable outcomes in terms of student results and satisfaction, comparable to, or higher than, other instructional methods. For example, meta-analyses specific to TBL have calculated significant positive effects on academic outcomes. Two meta-analyses that included mostly medical and pharmacy graduates calculated a mean effect size of 0.55 on content knowledge (16) and a nearly 0.5 standard deviation (SD) increase in average academic outcomes [17]. A meta-analysis showed significantly increased standardised mean differences (SMD) in theoretical examination scores and learning skills for various medical school subjects in China [18]. Similarly, a study [19] was conducted using a pre/post-test design to compare grade outcomes of a lecture-based course conducted over a regular semester with the same course taught over a summer semester using TBL, with nursing students in the United States of America (USA). Academic outcomes were significantly better by nearly 7% in the TBL course when assessed using a national standardised examination. Two systematic reviews have also reported moderate positive effects on academic outcomes, particularly for lower achieving students [13; 20]. TBL outcomes with mostly medical and pharmacy students in the USA were reviewed [13], whilst the other study [20] focused almost exclusively on undergraduate nursing and midwifery courses, mostly from the USA. A further study [21] also had similar findings.

Attitudes and satisfaction levels were also examined in four of the reviews and one meta-analysis. A significant increase was found in Chinese medical students' positive attitudes towards learning using TBL [18]. Another systematic review also reported overall higher student participation and enjoyment in TBL courses compared with standard lectures, albeit with some reluctance towards the change from lectures to TBL [20]. These findings are comparable to another study which showed attitudes toward TBL tended to improve with time [13]. This review also examined faculty attitudes, concluding that despite the additional workload associated with TBL, faculty approved of the increase in student engagement, and believed that the benefits of TBL outweighed the additional workload.

Overall, these reports suggest that TBL has positive effects upon academic outcomes and indicate moderate satisfaction and preference for TBL over other teaching methods. Positive academic outcomes and TBL attitudes have also been demonstrated specifically for nursing courses. However, the literature specifically regarding the outcomes of the TBL approach on the engagement, learning and satisfaction of nursing students is limited, even more so for East Asian nursing students.

Within a BN program delivered in Singapore, a model of keynote lectures followed by tutorials was previously employed. However, class sizes were growing (to around 300+) for these lectures and a different approach was needed to ensure more active learning was taking place and to increase student satisfaction. Team-Based Learning was introduced as a pedagogical method in the lecture sessions. Given the paucity of literature on the outcomes of TBL in East Asian nursing students, the research aim was to evaluate the implementation of this model in this cohort.

The research question was: What is the impact of TBL on student engagement, accountability for learning, self-reported preference for learning, and satisfaction in a transnational course for post-registration Singapore nursing students? We also examined the aspects of TBL that students found helpful for their learning.

Design

A cross-sectional survey design was used to collect quantitative and qualitative data to address the research question. This included the ‘Student Evaluation of Course’ (SEC) and an additional online survey. Grade outcome data were also collected from this course and other courses completed in the previous 18-month period.

Setting and sample

The study was conducted within an on-campus delivered ‘Professional Communication for Nurses’ course in a Bachelor of Nursing post-registration program delivered to a cohort of 305 Singaporean registered nurses in Singapore between February and July 2018.

TBL delivery

The TBL approach was introduced to the students during their first timetabled academic workshop and they were provided with live training on the process in the first lecture. Tutorials delivered by tutors appraised of TBL processes were used to support students focussing on the course content. The formal TBL approach was then implemented in subsequent large group lectures in the course. Team-Based Learning was delivered in structured phases of preparation, readiness and application, following the suggested stages below [22]:

1. Advance Assignment (outside of class)

Students were directed to the course/task outcomes and the resources needed to prepare them for this and were pre-assigned to teams. These materials were accessible via the Virtual Learning Environment (VLE) and discussed in tutorials. Students undertook this preparation both independently and within timetabled computer lab sessions.

2. Individual Readiness Assurance Test (iRAT)

Students undertook a multiple-choice iRAT in class. This occurred in the lecture setting. The students completed the test in readiness for discussion within the group element. At this stage answers are not revealed.

3. Team Readiness Assurance Test (tRAT)

The teams discussed the same questions in class and provided a team response to the same test as the iRAT. A scratch card was used (Immediate Feedback Assessment Technique; IF-AT), giving them three opportunities to get the answer correct. This provided immediate feedback to the students, which has been linked to positive outcomes and student satisfaction in some studies [23]. The answers are immediately apparent as the scratch card has an asterix under the correct answer. Individuals can then ascertain their own score as well as the team score. The iRAT provides a single point per question and the tRAT provides a maximum of three and a minimum of zero per question, depending on how many attempts the team takes for each question.

4. Instructor Clarification Review

Following revelation of the correct answers, the teacher discussed the issues identified in the tests and addressed any queries raised. Any questions that had been problematic for the students were identified and answers clarified. Here the teacher referred to the material that the students had been exposed to in the VLE or by other sources and provided brief explanations for clarification. At this stage students were also allowed to appeal or debate if they felt the answer was not correct, provided they gave a rationale with supporting evidence.

5. Team Application (tAPP)

Following the iRAT and the tRAT the students were provided with a problem/ scenario they must solve. They provided predictions and solutions to the problem and reported back on this via a shared online presentation platform.

6. Peer Review/Evaluation

The students underwent peer review using a scoring mechanism based on a ‘thermometer scale’ (cold, warm, hot) providing qualitative constructive comments on their team members.

Recruitment and data collection

Before recruiting participants, full ethical clearance was approved following a university ‘Human Ethics Review’ of the proposal and all methods were conducted in accordance with relevant regulations, policies, guidelines and ethical procedures..

Participation was voluntary and anonymous, therefore completing the survey was acknowledgement of consent. No personal data were collected.

The survey instruments included the Student Experience of Course (SEC), which is the standard anonymous university course assessment instrument, and a separate online anonymous TBL survey based on Mennenga's TBL-SAI (student assessment instrument) to investigate TBL experience and attitudes [24]. The SEC has five fixed response questions on a 5-point Likert scale examining student satisfaction with various aspects of the course such as teaching, assessment and delivery, and two open-ended questions seeking qualitative comments on what students found particularly good about the course and how the course could be improved. The expectation is that each course garners a minimum mean score of 3.5 in the SEC.

The author of the TBL-SAI, Associate Professor Heidi Mennenga [24] gave approval for its use in this study. The SAI instrument was slightly modified to align with the population/sample involved by the removal of two items that did not apply to the TBL approach taken with the participating students. Additional questions were provided for ratings and comments related to the student’s experiences, adjustment, TBL processes and enjoyment. The survey took no longer than 20 minutes to complete. The 31-item scale TBL-SAI (originally 33 in the unmodified version) used a five-point Likert scale to assess TBL experience by assessing three main domains: student accountability, preference for TBL over traditional lectures, and TBL satisfaction. Possible total subscale score ranges are 6–30 (18 neutral), 16–80 (48 neutral), and 9–45 (27 neutral) for accountability, preference, and satisfaction, respectively. Scores lower than the neutral indicate negative attitudes towards the domains. Higher scores indicate higher accountability for learning, a preference for TBL over lectures, and satisfaction with TBL. Overall scores are calculated via the addition of the subscale scores, and thus range from 31–155 (93 neutral). Higher scores are positively correlated with a positive TBL experience. As well as being validated by the author of the SAI, the tool has been further validated in other studies [25;26] that found it consistent and reliable in determining students’ preferences with the TBL.

The SEC survey was distributed by the university in an online VLE platform. The TBL-SAI survey was hosted on ‘Survey Monkey’. The online survey was not released until after the students had completed the course, assessments and the SEC to reduce any impact/influence that the lecturer may have had on students’ opinions, or motivation to complete the survey. No demographic data were requested as there was no intention to compare data amongst different age or gender groups in the analysis. The main criterion was that all participants were registered nurses in Singapore undertaking the post-registration BN program.

Data analysis

Analysis of the quantitative data from the online survey was performed via descriptive statistical analyses using SPPS Version 24. Scale reliability was measured using Cronbach’s alpha. Student assessment results and the SEC data were compared with previous performance in this program.

Qualitative comments from the SEC and from the qualitative aspect of the online survey were placed into NVivo 12 and analysed via thematic analysis [27] to identify and describe the key aspects of the student TBL experience and opinion. Thematic analysis requires a logical, traceable and clearly documented process to be trustworthy [28], so the following six steps were followed by the team:

Data familiarisation - reading and re-reading of the transcripts so that initial ideas can be recorded.
Data coding– assigning codes to significant aspects of the data in order to group similar data together.
Theme search – collating the coded data into potential themes.
Theme revision – revising the identified themes in order to create a thematic ‘map’ that relates to both the codes and the entire data set.
Theme definition – naming and clearly defining each theme.
Writing up – reporting the analysis with relevant code and theme examples as well as the thematic ‘map’ [27].

A population of 305 students were eligible to participate. Eighty-two students (27%) completed the SEC and 68 (22%) completed the online survey.

Online Survey

Table 1 displays the means and standard deviations (SD) for the TBL Student Assessment Instrument. These results show moderately positive outcomes for all three subscales, resulting in a moderately favourable overall experience with TBL compared to lectures. Scale reliability was satisfactory for the accountability (.737) and TBL preferences (.774) scales, and excellent for the TBL satisfaction scale (.921).

Table 1

The Team-Based Learning Student Assessment Instrument descriptive statistics.
Subscale	N	Mean (SD)
Accountability	68	22.2 (2.8)
Preference	68	52.7 (6.3)
Satisfaction	67	33.5 (5.1)
Overall	67*	108.5 (12.2)
*One participant did not answer the questions relating to the satisfaction subscale and thus could not be included

Table 2 displays the means and standard deviations for the remaining questions. These were rated on a scale from 1 to 10. Higher scores indicated students favoured TBL. The results show modest positive results for all questions.

Table 2

Descriptive statistics for the additional questions.
Question (descriptive answer range)		N	Mean (SD)
How would you rate your experiences of the Team Based Learning approach overall? (poor to excellent)		68	6.8 (1.6)
How difficult/easy was it to adjust to learning via the TBL process? (very difficult to very easy)		67	6.2 (1.6)
How would you rate…? (poor to excellent)	…the engagement or interaction experienced in TBL classes?	68	6.7 (1.5)
How would you rate…? (poor to excellent)	…your own level of learning from the TBL process?	68	6.6 (1.3)
Please rate the following TBL steps in terms of how useful each was to your learning. (not useful to highly useful)	The (self) preparation readiness assurance phase	69	6.3 (1.7)
	The individual (iRAT) and team test (tRAT) processes	70	6.4 (1.5)
	The IF AT test resources (Scratch card process)	69	6.5 (1.7)
How enjoyable were the individual (iRAT) and team test (tRAT) processes? (not at all to very enjoyable)		70	6.8 (1.7)

Student Evaluation of Course (SEC)

The SEC asks student to agree or disagree with the following statements on a 5-point Likert scale: Q1 ‘This course was well-organised’; Q2 ‘The assessment was clear and fair’; Q3 ‘I received helpful feedback on my assessment work’; Q4 ‘This course engaged me in learning’; Q5 ‘The teaching (lecturers, tutors, online etc) on this course was effective in helping me to learn’; Q6 ‘Overall, I am satisfied with the quality of this course’. These scored a median 4/5 on the Likert scale in each item.

Performance

Table 3 displays the grade distribution achieved by the whole cohort in the course delivered using TBL. The overall mean score in this course was 72.89% (SD = 12.63) compared to a mean of 63.96% (SD 2.42) across the other four courses delivered in the program during the previous 18 months.

Table 3

Students’ course score performance comparisons across the programme.
Comparison of course mean scores	Course 1	Course 2	Course 3	Course 4	Overall Mean	SD
Other Course mean scores	59.84	64.7	66.01	65.32	63.9675	2.43
TBL Course					72.89	12.63

Qualitative Data

Qualitative data were obtained from the SEC qualitative statements, and from the qualitative element of the online survey tool. These were analysed via NVivo 12.

Four themes were developed following 245 original code references, and 17 theme revisions highlighted within the qualitative texts. These themes were Engagement, Learning, Process, and Challenges. Overall, the responses were positive about the experience of TBL, although some students did express some concern about the approach. This can be seen in Fig. 1 below:

Theme 1: Engagement

This theme drawn from 40 reference statements, encapsulated aspects related to activity, engaging and sharing with others, and team working as a result of the TBL process. Students appeared to enjoy the opportunity for working in teams and interacting with others:

Team based learning approach was very engaging and beneficial in understanding the course better.

Team based learning used in teaching is a good approach. It engages students more than traditional teaching methods.

Theme 2: Learning

This theme was drawn from 24 reference statements. These were related to the students demonstrating positive attitudes towards the learning experience and the learning/understanding gained in the process. Participants highlighted the value of the TBL approach in relation to their learning:

Team based learning is good to aid in learning process.

‘It’s basically putting my knowledge to a test to see what I have learned has retained.’ (SIC)

Especially at the end of IF-AT & tRAT where we get to challenge the lecturer with our own answers. This promotes critical thinking and allows students to learn in a unique way.

Theme 3: Process

This theme was drawn from 47 reference statements. It refers to the TBL aspects that the students experienced and their perceptions of them. The students seemed to enjoy the team-based learning process:

It is a fun and engaging way of learning and it has certainly benefitted me in my learning journey.

Team-based learning is really effective, as followed by feedback session where students can clarify the answers with the lecturer for any doubt or confusion.

Theme 4: Challenges

This theme was drawn from 43 reference statements and relates to aspects students reported as challenging or negative from their perspective. There were some aspects that students found impacted on their engagement:

‘I recalled the first trial was quite difficult because sometimes we hardly to express our opinions with others whom we don't know, and we weren't sure about the flow of TBL and how it worked.’ (SIC).

The members who are non-enthusiastic in contributing to the team's efforts.

Some challenges were identified in relation to learning:

Did MCQ for whole class without explanation, I didn’t feel I’m learning.

The process was also not without its challenges:

It is challenging and mentally draining to work on 100 MCQ and 1–2 scenario(s).

I prefer combination of traditional lecture with team-based

Environmental factors such as classroom layout were noted as the factors most affecting the approach including the noise when groups were working and discussing in their teams

‘Round table will be the best, sitting in a row can be difficult to do discussion’

TBL can be a bit noisy. Hard to focus.

The students also found the peer review aspect to be challenging as some were reluctant to criticise their colleagues:

‘No peer evaluations, it’s not true evaluation due to the Asian culture. Nobody will write honestly; majority are positive feedbacks.’ (SIC)

However, some students recognised the value of the peer review:

I like it. If they just say you're not good or you're good it doesn't help, but if it's constructive feedback, they tell you your improvement area it really helps.

The aim of this study was to evaluate the impact of TBL on student engagement, learning and satisfaction in a transnational post-registration BN course for Singaporean nurses. There was a moderately positive evaluation of these factors.

The results from the qualitative data collected via the SEC and TBL online surveys demonstrated that students enjoyed the engagement aspect of TBL, although some saw the formation of teams as challenging. This is a necessary process however, and one with several benefits once students work together in their teams. A meta-analysis [29], showed significantly improved team scores from individual scores, and noticeably so amongst nursing students. Therefore, the issue of team formation is one that needs careful consideration.

The results from the TBL survey are very similar to those from a study [30] with nursing students in the United Kingdom (UK), who found students also demonstrated positive scores in the satisfaction, accountability and preference scales of the TBL-SAI, indicating a preference for TBL over traditional lectures. Western approaches to learning and teaching might not always be preferred by Asian students, who would tend not to speak up when older adults are present in a group, nor would they challenge or question a teacher, however TBL provides them a legitimate arena in which to do both [3]. A previous systematic review [20] also identified positive aspects from using a TBL approach whilst acknowledging that there are still challenges to be overcome, such as was evident in this study, for example in relation to team formation and peer review/evaluation.

Peer review was unpopular as students did not enjoy giving low scores or negative comments. This could be related to the Asian cultural context, which is based on maintaining harmonious relationships, virtuous behaviours and recognising hierarchical relationships [3]. Our findings in relation to peer review differ from a study [31], which found that the peer review process increased students’ accountability in team tasks as they consistently found that team members that were not engaged tended to receive low scores and evaluations, which the participants in our study were reluctant to do.

In relation to learning the results were moderately positive, both in terms of self-reported learning on the SAI learning subscale, and also in terms of mean percentage scores for the course. Student performance was 9% better in this course when compared to mean scores in other courses delivered in the program over the previous two years, therefore almost a full grade higher. These are not ‘like for like’ courses, nor had there been a previous iteration of this course to draw a comparison with, so although outcomes are positive, caution must be applied in attributing this to TBL as other confounding factors may be present. However, a previous study [32], also showed an increase in grade performance after implementing TBL.

Students particularly enjoyed sharing their team answers and the reveal of the correct answers during the IF-AT aspect of the process. The SEC results demonstrated a level of satisfaction equal to or slightly higher than other courses delivered in the same program in the previous two years. There were many student comments about how they preferred TBL to traditional lectures as they were actively involved, and it ‘wasn’t boring’. A study [33], also found that Korean nursing students were generally satisfied with TBL, suggesting it has potential as a pedagogical approach with Asian students. However, some students suggested they would like some formal traditional lectures as well as the TBL.

Limitations

The survey response rates were low (22–27%), and we did not collect demographic data, limiting the ability to generalise these findings and attribute causation to the TBL approach. It has been demonstrated that online surveys tend to have response rates (average 34% across 207 studies) up to 15% lower than paper-based surveys [34]. The closeness of the lecturer to the delivery of the TBL and the research process is also a limiting factor, although the surveys were anonymous and the data were collected after grades had been finalised, which should reduce any potential related bias. While it is possible that there was a selection bias towards those students who had a positive experience with TBL there were still comments that some students preferred traditional lectures.

Implementation of TBL with this East-Asian cohort on a transnational program demonstrated evidence of moderate positive engagement, learning and satisfaction scores when compared to traditional didactic lectures. Most students did appear to enjoy TBL and prefer it to their previous experiences of didactic lectures. The peer review process was challenging and not enjoyed by students, as they did not wish to appear critical of their colleagues, nor be humiliated within their team. A more anonymous online version of peer review may help students be more forthcoming in this area. Grade outcomes, which were higher compared to other courses in the program, provide some level of evidence that TBL can positively impact learning and performance or at least that it does not disadvantage students. Further research is required in this setting to quantify learning outcomes from utilising a TBL approach and to make wider comparisons with other demographic groups.

BN: Bachelor of Nursing

IF-AT: Immediate Feedback Assessment Technique

iRAT: Individual Readiness Assurance test

SAI: student assessment instrument

SD: standard deviation

SEC: student evaluation of course

SMD: standardised mean differences

tAPP: Team Application

TBL: Team Based Learning

tRAT: Team Readiness Assurance Test

USA: United States of America

VLE: Virtual Learning Environment

Ethics Approval and consent to participate

Ethics approval was granted via the University Human Research Ethics Committee (2018/060). All potential participants were provided with a participant information sheet. Consent, confidentiality and anonymity were secured, as all participant information was anonymous within survey and evaluation data. The main researcher was also the lecturer involved in the delivery of the TBL sessions and sent out the email request for participants for the survey. However, all participants in the survey were anonymous self-selecting volunteers, and could not be identified by the researcher and data collection occurred after course results were finalised.

Consent for publication

Not Applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The project was supported by a University Grant for Learning and Teaching.

Authors' contributions

RB, TA and VK contributed to the initial conception and design of the project, interpretation of the data, editing, drafting and revising of the manuscript.

Acknowledgements

To Stephanie Hansen for assistance with ethics applications, data analysis and literature search.

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No competing interests reported.

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Editorial decision: Major revision
19 Mar, 2021
Reviews received at journal
16 Mar, 2021
Reviewers agreed at journal
06 Mar, 2021
Reviewers invited by journal
05 Mar, 2021
Editor assigned by journal
05 Mar, 2021
Editor invited by journal
05 Mar, 2021
Submission checks completed at journal
03 Mar, 2021
First submitted to journal
28 Feb, 2021

You are reading this latest preprint version

Evaluating Team-Based Learning in a Transnational Post Registration Bachelor of Nursing Program in Singapore

Status:

Version 1

Abstract

Figures

Background

Methods

Design

Setting and sample

TBL delivery

1. Advance Assignment (outside of class)

2. Individual Readiness Assurance Test (iRAT)

3. Team Readiness Assurance Test (tRAT)

4. Instructor Clarification Review

5. Team Application (tAPP)

6. Peer Review/Evaluation

Recruitment and data collection

Data analysis

Results

Online Survey

Student Evaluation of Course (SEC)

Performance

Qualitative Data

Theme 1: Engagement

Theme 2: Learning

Theme 3: Process

Theme 4: Challenges

Discussion

Limitations

Conclusions

Abbreviations

Declarations

Ethics Approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgements

References

Additional Declarations

Status:

Version 1