Improving Learning Experience Through Implementing Standardized Team-Based Learning Process in Undergraduate Medical Education

doi:10.21203/rs.3.rs-4366580/v1

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Research Article

Improving Learning Experience Through Implementing Standardized Team-Based Learning Process in Undergraduate Medical Education

https://doi.org/10.21203/rs.3.rs-4366580/v1

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published 07 Oct, 2024

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Introduction

Team-Based Learning (TBL) is a highly structured active learning methodology shown to have positive learning outcomes in undergraduate medical education (UME), including improved acquisition of knowledge and teamwork skills. While many medical schools have increasingly adopted TBL, there is considerable variation reported in the literature in the implementation of the standard sequence and key components of TBL. This study aims to assess the impact of implementing the standardized framework of the TBL process on student perception of the benefits of TBL.

Methods

Faculty at our institute were surveyed to determine the frequency of implementation of TBL standards, as described in the literature. Second-year osteopathic medical students (OMS II) were surveyed for their perception of the experience of TBL at the beginning of the academic year. Curricular interventions targeting the enforcement of the standard steps and key components of TBL were implemented in a particular 6-week system course. The students were re-surveyed at the end of the course. Descriptive and thematic analyses were performed on quantitative and qualitative data.

Results

Twenty four of 31 (77.4%) faculty participated in the faculty survey, 53 of 105 OMS II students (50.4%) participated in the pre-intervention survey, and 72 of 104 OMS II students (69.2%) participated in the post-intervention survey. Faculty survey results indicated inconsistent implementation of key steps and components of the TBL process. Comparisons of student pre- and post-survey means of the perceived value of various aspects of TBL showed significant improvement in multiple aspects of the TBL process, including readiness assurance tests, immediate feedback, and application activities. Both before and after the intervention, students highly rated the value of teamwork and opportunities for practical application of concepts within TBL.

Conclusion

While medical students value teamwork in UME and professional development, their perception of TBL can be less than positive if not conducted deliberatively. Assessment of the implementation of the standard TBL steps and components and development of corresponding targeted interventions may improve the TBL experience of medical students. Our process could be generalized to help educators interested in improving the quality of TBL in their home institutes.

Team-Based Learning

Undergraduate Medical Education

Teaching Method

Adult Learning

Medical Students Learning

Team-Based Learning (TBL) is a pedagogical strategy that encourages active learning through small-group interactions that focus on application of knowledge and development of teamwork skills. During TBL sessions, students work together to solve real-world problems by applying knowledge and concepts acquired through pre-class preparation material.¹ Initially developed by Larry Michaelsen for use in business school, this approach to student-centered learning has been increasingly adopted in health professions education.²

TBL is a highly structured form of learning, involving the performance of a prescribed sequence of steps and the implementation of key components. The TBL sequence for each class session involves pre-class preparation, readiness-assurance process consisting of Individual Readiness Assurance Test (IRAT), Team Readiness Assurance Test (TRAT), immediate feedback and clarification, followed by problem-solving activities, and a closing summary. There are 4 key components to TBL: carefully formed and managed teams, frequent and timely feedback, problem-solving activities, and student peer evaluation.³ This sequence of steps and key components comprise the structured TBL process, which holds students accountable for completion of the pre-class preparation material and active participation as a team member, and also allows for multiple opportunities to apply and integrate conceptual knowledge through problem-solving. Books and practice guidelines have been published to describe the standardized framework of the TBL process and guide its appropriate implementation in the health care professions.^4,5

In undergraduate medical education (UME), TBL has the potential to allow for an integrated approach to the development of students’ problem-solving skills in tandem with professionalism, communication, and teamwork skills. Studies indicate students perceive TBL activities as increasing student engagement, enhancing critical thinking skills, and providing the opportunity to collaborate in teams.^6,7 Likewise faculty report increased engagement with TBL compared to traditional lectures.⁸ Studies also indicate the use of TBL in UME can help improve academic performance, especially for lower-performing medical students.^7,9,10 However, challenges are also reported in the literature, such as students perceiving an increased workload due to the flipped classroom format,³ and TBL sessions being time-consuming for faculty to develop.^11,12

Recognizing the potential benefits of TBL, a growing number of medical schools have adopted TBL practices in their UME curriculum.¹³ With the highly structured nature of TBL, the implementation of the standardized framework of the TBL process can be complex, and evidence exists of frequent modifications of TBL design and delivery upon implementation.² Systematic reviews continue to note extensive variation in the design and delivery of TBL in the health professions and UME.¹³ Parmelee and Michaelsen propose that TBL works best when all aspects are implemented.¹⁴ This leads to questions regarding whether individual design elements of TBL are most beneficial, or if the interplay of all the design elements in the overall structure of TBL are key to successful learning outcomes.

As a new osteopathic medical school, our institute has utilized TBL as a teaching method in preclinical courses during students’ first and second year of medical school. With the knowledge that the TBL structure is highly complex and that upon implementation is often modified with variations in its design and delivery, we initiated a survey of faculty within our institute to determine how often the various steps and key components of the TBL process were being implemented. The standardized framework of the TBL process was then fully implemented in a particular preclinical course, and student perception of the benefits of TBL were assessed via survey prior to and after this intervention. Our study aims to assess the extent to which the standardized framework was adhered by faculty and evaluate the impact of implementing the standardized framework of the TBL process on student perceptions regarding the benefits of TBL.

Setting

This study was conducted at Sam Houston State University College of Osteopathic Medicine (SHSU-COM) in academic year 2022–2023. SHSU-COM’s inaugural class started in Fall 2020. From its inception, TBL was established as a weekly two-hour session taking place on Fridays in all preclinical courses. Faculty received basic training on how to conduct TBL from the Division of the Educational Affairs at SHSU-COM.

To evaluate the extent to which the various aspects of the TBL process were implemented by faculty at SHSU-COM and students’ perception of their TBL experiences, we conducted surveys of faculty and OMS II students at the beginning of the academic year. Surveys were distributed via Qualtrics, and participation in all surveys was voluntary and anonymous. The faculty survey consisted of demographic and background questions and 16 Likert scale rating items for the frequency of implementation (1-never, 2-rarely, 3-sometimes, 4-often, 5-always) of the sequence of steps and key components of the TBL process.^1,3,4 The student survey contained demographic and background questions, 22 Likert scale rating items for perception (1-strongly disagree, 2-agree, 3- neutral, 4-agree, 5-strongly agree), and open-ended questions regarding advantages, disadvantages, and barriers to TBL implementation. The Likert scale rating questions were edited from a validated TBL evaluation instrument with the author’s permission.¹⁵ Based on the survey results suggesting variation of TBL design and implementation among faculty and best practices of TBL from the literature, curricular interventions targeting the enforcement of standard steps and key components of the TBL process were implemented in a particular 6-week course in the following semester as described below. The OMS II students were re-surveyed using the same survey at the end of the course to evaluate the effectiveness of the intervention.

General context/scope of TBL implementation:

The TBL targeted interventions were implemented in a six-week Endocrine Reproductive Genitourinary (ERG) systems course in spring semester 2023. This course consisted of 12–16 hours of weekly didactic sessions, primarily delivered in traditional lecture format. Based on literature review, standards of TBL were implemented in the TBL process. A total of 104 OMS II students were enrolled in the course, which contained three 2-hour TBL sessions, held on the 3rd, 4th, and 5th Mondays of the 6-week course. The primary faculty member involved in the TBL design and delivery had 3 years of prior experience with TBL and worked alongside 3 additional faculty facilitators. The students had participated in TBL for 1.5 years prior to the intervention, due to exposure in prior courses taken at SHSU-COM. Students were randomly assigned to teams by the Division of Educational Affairs at our institute. The class was divided into 14 teams with seven to eight learners per team, with all teams in one large classroom with each team sitting at their own table. The course grading breakdown was: TBL 20%, final exam 80%. The TBL portion of the grade was subdivided as 9% IRAT (3% each session), 9% GRAT (3% each session), and 2% peer evaluations (completion grade).

Preclass preparation

TBL preparatory work consisted of the previous week’s lecture-format didactic sessions. The lectures required for the preclass preparation were clearly specified, and learning objectives were provided. TBL sessions were held on Mondays rather than Fridays to increase the students’ time to review and study the assigned didactic sessions prior to the TBL sessions.

Readiness Assurance

Two readiness assurance assessments were used: IRAT and TRAT. The IRAT consisted of 10 multiple choice questions, which each student took individually. The IRAT was immediately followed by the TRAT, which consisted of students answering identical questions as a team. No use of books, notes, or other materials was permitted during either assessment. The appeals process for grading was an informal process in which students brought questions or concerns directly to the main instructor during the TBL session.

Application Activities

The application activities consisted of problem-solving activities during which students applied concepts from the previous week’s lecture sessions to clinical cases. Cases were carefully selected to stress significant concepts from the previous week’s material. While in previous courses, TBL modules had typically consisted of one in-depth case, multiple cases were covered in one session through the addition of mini-cases that enabled the application of additional key concepts from the pre-class preparatory material. Specific time goals were set ahead of time for each case to ensure all material was covered and that there was sufficient time for a wrap-up at the end of the application activities. During the application activities, there was initial intrateam discussion with intermittent breaks of interteam discussion.

As described in the literature, the 4 S’s (Significant problem, Same problem, Specific choice, Simultaneous reporting) of TBL were adhered to during the TBL sessions.⁵ This was done by inserting periodic stopping points where teams reported their answers to questions to the entire class. Questions were significant to the case being discussed, had specific choices, and were the same for all groups. Following intrateam discussion, all the teams were asked to display their selected answer at the same time by raising the associated A-D placards. Specific teams were asked to address these questions and explain their rationale; other teams were given the opportunity to respond.

Immediate Feedback

Students received immediate feedback frequently throughout the TBL. During the TRAT, the student teams had to reach the correct answer before they could move to the next test item. Clarification of frequently missed IRAT/TRAT items was provided by faculty. Feedback was provided throughout the application activities by faculty facilitators, and there were periodic stopping points during the application activities to ensure all teams were keeping pace with the cases and had the correct answers to the questions during the TBL. Each case contained a closing summary, and the session conclusion was delivered by the main instructor.

Peer Evaluation

Based on best practices of TBL in the literature, peer evaluations were introduced into the TBL process. Students were required to complete a peer evaluation after they completed all three TBL sessions. For the peer evaluations, each learner evaluated their fellow teammates anonymously. Each learner was asked to provide quantitative ratings (1-rarely, 2-sometimes, 3-usually, 4-almost always) for a series of statements regarding their teammates, as well as open-ended responses regarding their teammate’s strengths and opportunities for improvement. Each student had access to the anonymous feedback that their team members had provided them.

Analytical procedure

All data were stored in Microsoft Excel workbooks. Descriptive statistics were calculated for each Likert scale question with reported averages following the format of the mean ± standard deviation. Participation in the surveys was voluntary and anonymous. Individual students’ response to the pre- and post-survey was not collected in order to ensure the anonymity of participants. Thus, the pre- and post-survey responses could not be compared on the level of individual students, and comparison was limited to the student group comparison rather than individual student’s responses. The anonymity of data collection also prevented us from discerning if individual students chose to participate in only one or both surveys. For these reasons, pre- and post- student survey results were compared using unpaired t-tests.

The narrative feedback provided by students from both pre- and post-survey was analyzed using constant comparison analysis.¹⁶ Two investigators (YZ and RAD) double coded the de-identified student feedback with Dedoose 9.0.107 to independently assign codes to the text for each question. The investigators then reviewed the accuracy and relevance of these codes according to their interpretation of the students’ meaning and used the software to merge similar codes and remove other codes that were no longer pertinent. Next, the investigators used printouts from the software to complete axial coding, which involves comparing text segments and codes to create categories made up of similar codes, and to combine categories into broad themes. The data were entered into Microsoft Excel for data management.

IRB exemption for this research project was granted by the IRB committee of SHSU.

Quantitative results

A total of 24 of 31 (77.4%) faculty participated in the faculty TBL survey. Among them, 11 (46%) were females and 13 (54%) were males, 8 (33%) had a degree of Doctor of Philosophy (PhD), 16 (67%) had a medical doctor degree of either Doctor of Osteopathic Medicine (DO) or Doctor of Medicine (MD), and one faculty had dual MD and PhD degrees. All faculty reported some experience with TBL ranging from less than a year to over four years. However, only 15 (63%) faculty reported that they have led the design and delivery of at least one TBL session in the past. Among these 15 faculty, 2 (13%) reported having less than one year experience with TBL, 5 (33%) reported 1–2 years of experience, and 8 (53%) reported more than 2 years of experience. When asked how frequently faculty implement aspects of the TBL process as listed in Table 1, the data reveals a large variation in how often specific steps and components of TBL were implemented.

Table 1

Frequency of the Implementation of TBL Steps and Components by Faculty
TBL Steps/Components	Mean	Std Deviation
Student peer evaluation process	2.13	0.96
Use of appeals process	2.20	1.33
Team formation based on criteria to assure diversity in teams	2.93	1.44
Immediate feedback following the TRAT	3.13	1.02
Peer review of TBL module by other faculty	3.33	1.53
Teams reporting their answers to problems simultaneously	3.73	1.39
Immediate feedback on application activities	3.80	1.17
TRAT consisting of same items as IRAT	3.93	1.34
Relevant in-class application activities designed to apply knowledge from preparatory material	4.07	1.12
Teams working on problems with specific answers	4.07	1.18
Assignment of pre-class preparation material	4.13	1.20
Teams working on the same problem at the same time	4.20	1.22
Team Readiness Assurance Test (TRAT)	4.27	1.24
Individual Readiness Assurance Test (IRAT)	4.33	1.25
Closing summary of main learning objectives	4.40	0.71
In-class activities with content application	4.53	0.72

In total, 53 of 105 OMS II students (50.4%) participated in the pre-survey. Among them, 37 (69.8%) were females and 16 (30%) were males. Seventy-two of 104 OMS II students from the same cohort (69.2%) participated in the post-survey after the implementation of TBL standards in the ERG system course. Forty-seven of them were females (65%) and 25 (35%) were males.

The 22 survey items were categorized into three parts: TBL Process, Teamwork, and Benefits of TBL. In TBL Process, significant increase in student perception was found in all items except for pre-class preparation. (Table 2) Students reported improvement in multiple components of the TBL process, including pre-class preparation, IRAT, TRAT, application activities, and immediate feedback. Interestingly, in both surveys, students acknowledged that they consistently lacked pre-class preparation. (Table 2)

Table 2

Student Perception Before and After the TBL Intervention Regarding the TBL Process
TBL Process	Pre-Survey Mean (StD)	Post-Survey Mean (StD)	p-value
Team members were appropriately selected to maintain equality between groups.	3.49 (0.92)	4.01 (0.94)	< 0.01
The learning objectives of TBL helped me focus on core information.	3.32 (1.13)	4.08 (0.91)	< 0.001
The content of the pre-class preparation provided was in line with the proposed learning objectives.	3.72 (0.68)	4.18 (0.87)	< .01
The amount of content available for the individual pre-class preparation was reasonable.	3.19 (0.89)	4.13 (0.87)	< 0.0001
I consistently reviewed the pre-class preparation materials prior to TBL sessions.	3.36 (1.23)	3.76 (1.16)	0.07
Individual Readiness Assurance Tests were useful learning activities.	3.49 (0.96)	4.17 (0.94)	< 0.001
The team discussions during the Group Readiness Assurance Test allowed me to correct my mistakes and improved my understanding of the concepts that are used in TBL case discussion.	4.08 (0.89)	4.39 (0.64)	< 0.05
The TBL clinical problem-solving activities were useful learning activities.	3.42 (0.98)	4.38 (0.75)	< 0.0001
In the discussion of the clinical case, teachers consistently acted as learning facilitators.	3.60 (0.96)	4.49 (0.69)	< 0.0001
I consistently received immediate feedback during TBL discussions.	3.06 (1.02)	3.99 (0.87)	< 0.0001

In the Teamwork category, all relevant items were significantly increased in the post TBL interventions. (Table 3) It is noteworthy to mention that most items were already rated above 4.0 (agree) in the pre-survey. Although there is a significant increase regarding student perception of how other students pay attention during TBL sessions, the post-survey rating for this particular item is still below 4.0. (Table 3)

Table 3

Student Perception Before and After TBL Intervention Regarding Teamwork
Teamwork	Pre-Survey Mean (StD)	Post-Survey Mean (StD)	p Value
Most students were attentive during TBL sessions.	2.87 (1.20)	3.81(0.95)	< 0.0001
My team worked well together.	4.04 (0.70)	4.50 (0.60)	< 0.001
There was mutual respect for other teammates' viewpoints during TBL.	4.04 (0.82)	4.53 (0.58)	< 0.001
I have a positive attitude about working with my peers.	4.06 (0.71)	4.46 (0.62)	< 0.01
I contributed meaningfully to the TBL discussions.	4.09 (0.68)	4.39 (0.61)	< 0.05

In the category Benefits of TBL, all survey items were significantly increased post intervention except for two items associated with the value of teamwork: solving problems in a group and the ability to collaborate with peers, which were highly rated both prior to and post intervention. (Table 4)

Table 4

Student Perception Before and After TBL Intervention Regarding the Benefits of TBL
Benefits of TBL	Pre-Survey Mean (StD)	Post-Survey Mean (StD)	p-value
The TBL format helped increase my understanding and application of the course material.	3.47 (1.00)	4.43 (0.72)	< 0.0001
TBL sessions encouraged me to progress beyond acquiring factual knowledge by helping me achieve a greater depth of understanding.	3.4 (0.92)	4.11 (0.99)	< 0.0001
TBL helped me prepare for course examinations.	3.53 (1.00)	4.26 (0.88)	< 0.0001
I learned useful additional information during the TBL sessions.	3.60 (0.94)	4.35 (0.77)	< 0.0001
Solving problems in a group is an effective way to practice what I have learned.	4.21(0.81)	4.40 (0.70)	0.17
The ability to collaborate with my peers is necessary if I am to be successful as a physician.	4.68 (0.51)	4.61(0.57)	0.48

To specifically evaluate the impact of the newly implemented peer evaluation process in the intervention, we asked two new questions in the post survey. Students rated 3.64 (1.19) for the question “Receiving feedback from my peers regarding my participation in the TBLs was useful.” and 2.97 (1.37) for the question “Knowing I would receive feedback from my peers changed how I interacted with them during the TBLs.”. These data suggest that students place less value on the peer evaluation process and feedback than other components of the TBL process.

Overall preference of TBL to traditional lectures improved significantly from 2.51 (1.13) to 3.22 (1.13), but continues to be one of the lower rated items on the survey.

Qualitative results

Pre-Intervention Survey

The pre-intervention student survey contained three open-ended questions regarding students’ perception of the advantages, disadvantages, and barriers of utilizing TBL as a teaching tool in general. Constant comparison analysis reveals several dominant codes for each question.

For the advantages of TBL, the top three dominant codes include students value teamwork, TBL provides opportunity to apply knowledge, and TBL provides preparation for exams.

Student #1 commented: “Working together as a team and being able to share our strengths. Individuals who were knowledgeable in a certain topic were able to explain to other in the group.” Student #2 commented: “Working as a group helps develop skills in interpersonal communication and teamwork.”

Student #3: “All week you are learning material but in the TBL you receive a case scenario and have lab values and you begin to actually apply the material as if you are seeing a real patient. Each slide comes with information and questions that groups can discuss which promotes critical thinking.”

As the readiness assessments in TBL sessions were mostly used to test the weekly material at our institute, some student felt TBL provided “incentive to keep up with and integrate material before exams.” (Student #4)

For the pre-intervention survey regarding disadvantages of TBL, the dominant codes include challenges in preparation, lack or inefficient faculty facilitation, student disengagement.

The major student concern regarding the preparation for TBL is the large amount of material for the amount of time they have to study before the TBL. “… the week is so much material, it would be great to have the weekend to really spend time with the material so that when we do TBL, we are able to come more confident in the material to really use the team based approach and clinical applications to deepen our understanding.” (Student #5) “Deep understanding of concepts has not fully solidified prior to TBL due to lack of time for preparation prior to individual quiz.” (Student #6)

Several students commented on the deficient or inefficient faculty facilitation as the reason that some TBL sessions were not effective. “Almost every TBL group I was in would talk for a little bit, but then everyone just did things individually when they were done... so the clinical application of the material was great, but it didn't completely foster group interaction like it should.”(Student #5) A similar comment from student #2 is: “Since instructions act as facilitators rather than instructors, it can be difficult to get help when the group is struggling. "Figure it out yourself" is not always a helpful response. I would appreciate more feedback and guidance when a group is struggling and have exhausted outside resources.”

For the pre-intervention survey regarding the barriers of implementing TBL at our institute, students echoed the inconsistency of faculty in delivering the TBL sessions as well as the amount of materials and limited time they have to prepare for the TBL.

Post-Intervention Survey

After the intervention, students were re-surveyed, and open-ended questions regarding the advantages, disadvantages and recommendations for improvement of TBL specifically targeted students’ perceptions of how TBL was utilized in the ERG course. For the advantages, the dominant codes included two similar codes to the pre-intervention survey: practical application of content and team participation. Additional dominant codes identified in the post-intervention survey were organization and formatting of TBL, and help solidify learning.

Student #7: “I enjoyed how there were practice questions that our groups had to answer together because we talked about the answers together and got to see how we thought if different ways”. Student #8 commented regarding the advantages of TBL utilization in the ERG course: “They were great for applying the knowledge we had learned to case based situations”, and Student #9 stated “Practical application of content gives way to better learning experience”. Several interventions associated with the organization and formatting of TBL were highlighted by students. The first is regarding the readiness assessment process. Having the same questions for IRAT and TRAT, having TRAT immediately following IRAT, and having equal weight for IRAT and TRAT were positively commented on by the students. Student #10: “The format of iRAT, gRAT, Case, Explanation is very beneficial. Having the gRAT immediately following the iRAT provides closure for the iRAT and allows students to focus on the case. I appreciated the explanations of the cases in this course.”

Secondly, students commented frequently on the pacing and segmenting of the application activities. Student #11 mentioned “I liked the pace of the cases and being able to answer a lot of high yield questions throughout the case”. Student #12: “There was good balance of enough material to keep us going but not too fast that we cannot keep up”. Student #13: “I like the segmental format where we do a case then pause and talk as a group before moving onto the others. I feel like starting and stopping forces me to pay more attention. When we work amongst ourselves entirely until the end I find that there is a lot of dead space that is filled with chatter.” Students also commented on the quality of the application activity questions and how they were built into the case discussion. Many students referred to application activity questions as ‘practice questions’. Student #14 mentioned: “I liked how there were practice questions built into the TBL cases and how we walked through them together.” And student #15 said: “I loved the case studies and how we were able to work through and had additional practice questions. Very good!”

Thirdly, several students also commented that they preferred TBLs to be on Mondays instead of Fridays. “I prefer TBLs on Monday because it gives me an opportunity to actually learn the material over the weekend rather than cram on Thursday night.” (Student #16)

Several students specifically mentioned that TBL helped them “solidify what was taught in class by applying it in case scenarios”. (Student #17) “It helped me solidify information and let me know what was important.” (Student #18)

For the post-intervention survey regarding the disadvantages of how TBL was utilized in the ERG course, the dominant codes included no disadvantages and the amount of materials needed to review for TBL. Student #19: “I do feel that too many sessions were included on each TBL making it difficult for students to focus their studying.” However, students most commonly commented that there were no disadvantages.

In response to the question ‘What are your recommendations on how TBL sessions at SHSU-COM can be improved?’, students particularly commented on using the TBL in ERG course as a model, keeping TBL on Monday, and keeping the format of IRAT and TRAT as in the ERG course.

With the transformation witnessed in health professions education over recent decades, there has been a shift away from conventional didactic lecturing towards pedagogical approaches that actively engage learners.^17–19 TBL, as an instructional strategy, is specifically crafted to foster the growth of high-performing learning teams and create avenues for these teams to participate in substantial learning activities.³ TBL is becoming increasingly prevalent in medical school education^{7,10,11,17,18}, with much variation described in the literature regarding the frequency of implementation of the various core design elements of the standardized TBL process.¹³ Our study likewise found wide variation reported by faculty at our institute in the frequency of implementation of various TBL steps and components. After identifying this variation, targeted interventions were developed with the goal of improving the quality of TBL by adding back the structured sequence of steps and key components of the standardized TBL process. Post the intervention, there was a significant increase in students’ positive perception regarding the TBL process, teamwork, and benefits, demonstrating the effect of following the standardized framework of the TBL process on student perception of learning experience and outcomes.

The interventions in our study were targeted at implementing each of the individual steps and key components of the TBL process in accordance with established guidelines in the literature.^1,3,4 Specifically, pre-class preparation was defined and communicated clearly, readiness-assurance procedures were followed with an identical IRAT and TRAT given, application-oriented activities stressed the 4 S’s and frequent immediate feedback, and a peer evaluation process was implemented. Our data show the student perception of the value of each individual TBL element rose with the implementation of all the key elements of TBL. This suggests the interplay of different steps and components of the TBL process leads to positive student perception of each aspect of TBL, rather than individual elements being the ‘best part’ of TBL. This supports Parmelee and Michaelsen’s proposal that TBL works best when all elements are included in its design and implementation.¹⁴ The interplay of different aspects of TBL on learner attitudes and academic outcomes has been identified in the literature as an area warranting further study.²

Several survey items related to teamwork had similarly high ratings by students both before and after the TBL intervention. These data suggest that the students highly value the importance of teamwork and find that TBL provides an opportunity to apply problem solving skills to address real world challenges in a team environment, even before the standardized framework of TBL was implemented. Students in our study report feeling that problem-solving in teams is an effective learning method, having a positive attitude towards working with their peers, and believing the ability to collaborate with peers is a necessary skill as a physician. We believe this positive attitude is associated with the more evident significance of teamwork in healthcare, emphasizing a team-oriented approach to patient care.¹⁹ Various pedagogies have been reported to teach teamwork skills for medical students and residents.²⁰ TBL provides a structured approach for learners to develop professional skills key to teamwork such as communication, group problem-solving, and accepting and receiving feedback.

Our data suggest that a key aspect driving students’ positive perception of the benefits of TBL is the organization and formatting of the TBL sessions. An aspect of TBL organization that students in our study reported appreciating was having TBL sessions on Mondays instead of Fridays, with students reporting this increased the amount of pre-class preparation time available to students. The formatting of the TBL instructors’ facilitation methods also appears to be key to student perception of the benefits of TBL. Students in the post-intervention survey frequently commented on the quality of the facilitation of the application activities, and specifically expressed their appreciation of frequent feedback during the clinical cases. Students correlated the frequent periodic stopping points in the application activities as fostering increased student engagement and accountability. Without appropriate facilitation, students may feel they are ‘teaching themselves’ and doing the work of their teachers.²¹ TBL allows facilitators to frequently assess and address learner understanding and problem areas,^4,5 and in our study provision of frequent feedback by the facilitator appeared to enhance student perception of their learning and solidifying of concepts.

Another key facilitation skill appears to be pacing, with multiple survey respondents commenting on the beneficial pacing of the application activities. Time management during TBL sessions has been identified as an important TBL facilitation skill.¹⁴ As part of our intervention, multiple cases were covered in each TBL module, and specific time goals for each case were set and enforced by the primary TBL facilitator to ensure all material was covered and that there was sufficient time for a closing summary of key points. Qualitative analysis of the student survey responses indicated students associated this pacing with being able to efficiently cover a large amount of key content.

The lowest rated items on the post-intervention survey were peer evaluation, indicating students found this aspect of the TBL process to be the least beneficial. Peer evaluation is described as a key component of TBL as it holds students accountable to contributing to the team, and also provides an opportunity to practice the important professional activity of giving and receiving feedback.³ However, a 2014 systematic review of TBL and UME found that only half of the articles reported a peer evaluation process,¹³ and a 2017 systematic review of TBL and health professions education found that learners were most critical of the peer evaluation aspect of TBL.² Multiple methods of peer evaluation are described in the literature, with formative and summative approaches described, and systems of assessment that can involve quantitative or qualitative assessment.²² While studies indicate that medical students identify the ability to give and receive feedback as a key professional skill in medicine, they have difficulty providing feedback regarding needs for improvement to their peers.²² Other studies report positive student perception of receiving peer feedback, and reliability of the peer evaluation process in determining student performance.^23,24 Given the wide range of methodological approaches and student perceptions reported in the literature for peer evaluations with TBL, these processes may need to be tailored to each institution, with consideration for needs analysis for different academic settings.

Interestingly, although students’ preference for TBL over traditional teaching methods increased significantly after the intervention in our study, TBL was still not perceived more positively than traditional teaching. The data from our study does not clearly indicate the reason for this neutral view of the value of TBL over traditional lectures, and several explanations may be postulated. In the post-intervention survey students identified the amount of time required for pre-class preparation as a disadvantage of TBL in the ERG course. Students’ perception of pre-class preparation time in TBL being challenging has been identified in the literature,³ and this may subtract from the value of TBL to students. Additionally, some studies have indicated students tend to prefer whichever learning modality they are first exposed to in relation to TBL.^25,26 Frame et al reported a higher reception of TBL in the group of students who received TBL first and traditional lecture-based learning next compared with the group that had the opposite sequence.²⁶ Similarly, students accustomed to problem-based learning did not perceive TBL as more engaging or beneficial.²⁵

The quality of training and the development of proficiency in TBL implementation and facilitation skills appear to be key to improving the institutional effectiveness of TBL usage. Strategies to implement this may include institution champions for TBL, the development of a faculty TBL team, and leadership buy in for investing in faculty training success. Resources such as the TBL Collaborative²⁷ provide institution and faculty with opportunities for formal training and platforms for sharing experiences.

Our study has several limitations. To ensure survey participation was completely voluntary and anonymous, we did not collect any identifiable data to track individual student’s perception before and after the TBL intervention. For this reason, unpaired t test was conducted. Second, the data presented is solely limited to student perception. Although student satisfaction is an important indicator for curricular effectiveness, it should not be the only measurement. Learning outcome data can contribute additional insight to the benefits of TBL, however, we did not have a control group to directly compare the effect of different pedagogy on student learning for the same materials. In addition, our study was not longitudinal and included only one iteration for three TBL sessions in one course, whereas studying TBL longitudinally, or after it has been employed for a minimum of three years, has been recommended in the literature.²

Our study evaluated the influence of the implementation of the standardized sequence and components of the TBL process on student perception of TBL effectiveness as an active learning methodology in UME. We found that students' perception of the value of individual elements of TBL rose with the implementation of all the design elements of the standard TBL process, suggesting that the interplay of the various steps and components of the structured TBL process leads to improved student perception of the benefits of TBL. With the expanding recognition and adoption of TBL in UME, our study indicates that it will be crucial for medical educators to implement TBL's standardized framework and to provide adequate support and training for instructors to ensure optimal student learning experiences. Additionally, ongoing assessment and refinement of TBL implementation strategies will be beneficial for maximizing the effectiveness of TBL in UME settings.

Ethics approval and consent to participate 

Decision of Exempt for this research project was granted by the IRB committee of Sam Houston State University. Informed consent was exempted by the IRB committee of Sam Houston State University due to retrospective nature of the study. All methods were carried out in accordance with the principles, guidelines and regulations of Declaration of Helsinki. 

Consent for publication 

Not applicable

Availability of data and materials 

All data generated or analyzed during this study are included in this published article. 

Competing interests 

The authors declare that they have no competing interests. 

Funding: Not applicable

Authors' contributions 

Y.Z. and R.A. designed the study and delivered all learning modules. They collected the data and conducted the qualitative data analysis and were major contributors in writing the manuscript. R.N., L.Z. and L.K. conducted the literature review and contributed to the writing of the manuscript. All contributed to the editing of the manuscript. All authors read and approved the final manuscript. 

Acknowledgements 

The authors thank Dr. Amber Sechelski for her recommendations on the qualitative analysis. 

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No competing interests reported.

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Improving Learning Experience Through Implementing Standardized Team-Based Learning Process in Undergraduate Medical Education

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Abstract

Introduction

Methods

Setting

General context/scope of TBL implementation:

Preclass preparation

Readiness Assurance

Application Activities

Immediate Feedback

Peer Evaluation

Analytical procedure

Results

Quantitative results

Qualitative results

Pre-Intervention Survey

Post-Intervention Survey

Discussion

Conclusions

Declarations

References

Additional Declarations

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Journal Publication

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