Ethical approval
Ethical approval was obtained from the biomedical research ethical committee at the FOM, KAU. In addition students were given relevant information on the study and a verbal consent was obtained prior to any interviews. The IRB was approved as waiver of signed consent given that the research presents no more than minimal risk of harm to subjects and involves no procedures for which written consent is normally required
Design and participants of the study
Second year full class Nursing students (n=70), Faculty of Nursing, second year Clinical Nutrition full class students (n=33), Faculty of Applied Medical Sciences, were all part of this study. Both groups of students received the same course of Clinical Biochemistry (BCHM 207), which covered basic cell metabolism, bioenergetics and molecular biology and which was given by the same teaching staff. In a case-control manner, the same tutor (Dr. Aliaa Alamoudi) taught the same Nucleic Acid (NA) section of the Clinical Biochemistry course to both groups of students. However, the Clinical Nutrition group of students were instructed in the form of a TBL session, while the Nursing students were instructed through traditional didactic lectures. The decision of which group to receive which teaching method was based on the logistics related to each faculty e.g. administration acceptance, and availability of classroom that can support the TBL session. Both groups consisted only of female students and of similar age, and there were no male students in either faculty, thus limiting some of the variables and differences that could have existed between female and male departments.
Both groups had successfully completed the same preparatory year, a requirement by the KSA Ministry of Education, before being considered eligible to continue their bachelor qualification studies starting the second year. In addition, both groups showed similar entry level grades for their second year.
To test and ensure the equity between both groups prior to the study, students were asked to submit at the beginning of their second bachelor studies year, their university entry exam scores of Qiyas which includes the General Aptitude Test (GAT) and the Scholastic Achievement Admission Test (SAAT), and the GPA of their preparatory year. A description of each of these tests and the students’ entry exam scores is described below.
Qiyas tests:
. Two main tests are mainly given by the National Centre for Assessment Qiyas as entry exams : the GAT and SAAT.
The GAT is a 120- question test that uses mathematical and verbal skills.
According to Qiyas, scores are analyzed as follows:
Student’s position
|
Test score
|
Top 5%
|
81 and above
|
Top 10%
|
78 and above
|
Top 20%
|
73 and above
|
Top 30%
|
70 and above
|
The average
|
65 and above
|
Lowest 30%
|
60 and below
|
The SAAT test on the other hand measures the overall achievement of students during their whole education journey in various subjects, and is scored out of 100.
NA section lectures
The NA section of the biochemistry course was given to the control arm of this study (Nursing students) in the form of traditional lectures. The section was taught via five lectures and a tutorial, covering: NA structure, DNA replication, Gene transcription, Post-transcription modification and Gene translation. Each lecture was given as a 60-minute power-point presentation to the students by Dr. Aliaa Alamoudi , and consisted roughly of 30-40 slides. Each lecture started with the expected student learning outcomes, a video related to the topic, text, graphs, and some questions related to the topic addressed. Attendance was not taken from students, however, it was estimated to reach around 70%. All lectures were given in a lecture hall, which had a capacity of around 200 students and was furnished with audiovisual equipment. In addition, all lectures and material were made available to students on blackboard (a learning management system software) 10 days prior to giving the lectures, and remained on the software afterwards.
TBL session design:
The Clinical Nutrition group of students on the other hand were instructed the NA part of the course via a single TBL session. A description of all the aspects of the TBL session is described in the sections below.
TBL orientation workshop
To ensure the readiness of the second year Clinical Nutrition students to be engaged in TBL, they attended a two-hour TBL orientation workshop. The students were first asked to reflect (in pairs) on the advantages and disadvantages of traditional lectures and their findings were then discussed amongst all of them. A video demonstrating the experience of TBL in other universities was then played. Afterwards, students were introduced (via a power-point presentation) to a detailed overview of TBL including: background, the pre-reading step, the Individual Readiness Assurance Test (IRAT), the Team Readiness Assurance Test (TRAT), scoring system, references, etc. Finally, students were asked to reflect on the anticipated advantages and disadvantages of introducing TBL and any queries from the students were addressed.
TBL Team formation:
Second year Clinical Nutrition students were divided based on their previous two clinical biochemistry quizzes scores into ‘A’, ‘B’, and ‘C’ students. Students were then divided into six groups of 5-7 students per group with each group containing equal numbers of ‘A’, ‘B’, and ‘C’ students. The students were distributed to their teams prior to the TBL in-class session.
TBL Pre-class reading
Prior to class, students were allocated compulsory readings and five power-point lectures. Each lecture was accompanied by the required student learning outcomes, detailed content, videos related to the topic, chapter of the required reference, and two to three assessment questions. This material was similar to the material provided for the Nursing students. All the material was uploaded on the blackboard online system ten days prior to the TBL in-class session. Students were informed that they could use the time slot allocated for their lecture time in the students’ time table for their pre-class reading whether in class or at the campus library without any tutor supervision.
TBL in-class session
TBL in-class session was conducted in two hours .The structure of the TBL in-class session was divided into the IRAT, TRAT, and problem- solving activities, similar to the classical TBL format (9, 11, 12, 15). The IRAT was given at the beginning of the session to assess the individual’s knowledge of the pre-reading. The test was provided as 10 MCQs with four options to select the single best answer, and was given in 15 minutes. This was followed by the TRAT, in which the same test was repeated by the students in their teams in order to promote discussion and allow team-work in reaching the consensus. The TRAT was conducted in 30 minutes. Teams who answered correctly on their first attempt received 4 points, while those who answered correctly on second attempt received 2 points, and 1 point was given to those who answered correctly on their third attempt in each question. The TRAT test was given as a scratch-off form, which provided the students with the answers of each of the questions immediately. A small summary of the answers was provided by the tutor after the end of the TRAT, and explanation was provided to address any difficult questions. Although a formal appeal process was not provided, the discussion was opened to allow students to challenge answers and ask questions. The final 30 minutes of the TBL session was used in problem-solving activities by the team. The teams received three problem (case scenario) activities, allowing them to apply conceptual knowledge on relevant cases or scenarios that fit with the specialty of their studies. Each case scenario had four possible answer choices for the teams to select the best answer. All cases followed the standard ‘4S’ framework in TBL (11, 12), in which all cases were a ‘Significant problem’, ‘Same problem for all teams’, ‘Specific choice’, and finally teams provided ‘Simultaneous report’.
TBL marks were divided as follows: 2 marks for attendance, 5 marks for the IRAT, 5 marks for TRAT and 3 marks for the case activity. The overall TBL session score was calculated out of 15 marks and was considered as the third continuous assessment in the biochemistry course besides Quiz 1 (15 marks) and Quiz 2 (15 marks). Students were informed that the highest two marks out of the three assessments would be included as continuous assessment marks (30 marks) out of their total 100 marks in the course. .
Pre- and Post-course Test
In order to ensure that both groups had a similar background in molecular biology before implementing our TBL experiment, a pre-course test was conducted for both groups. The test was in the form of 15 recall MCQs that covered basic information on the material, such as definitions, and basic concepts of gene expression in molecular biology, and was provided by a colleague member of the clinical biochemistry department to avoid any bias. The test was conducted by the Clinical Nutrition students prior to the start of the TBL workshop, and by the Nursing students prior to the beginning of their first NA lecture.
To evaluate whether TBL was able produce improved student comprehension of the subject, and whether the learned information was better retained and applied, a post-course test was conducted for both groups . Similar to the pre-course test, the post-course test was a 15 MCQ test that had both recall (10 questions) and reasoning (5 questions) dimensions and was constructed by three colleague members of the clinical biochemistry department who were not involved with this study or any of the NA lectures or TBL design to avoid any bias.
The test was given to both groups as a pop quiz a week after the end of both the NA lectures and TBL. Thus there was a total of two weeks apart between the pre and post test in both groups.
Final Biochemistry (BHCM) course exam and NA section exam
At the end of the term, both groups received a final summative exam made of a total of 60 MCQs based on a blue print covering all the term’s BHCM course material (protein structure, enzymes, carbohydrate metabolism, lipid metabolism, amino acid metabolism and finally NA). The exam was a three-hour exam, in which students are allowed to submit their papers after one hour and a half. The same 9 NA MCQs were used in both exams and the scores of both groups in these 9 questions were then compared.
Focus group interview:
One of the main aims of this study was to gain more insight into Saudi students’ impression of the TBL experience, as there was not an abundance of pre-existing data regarding their experience with this method of teaching. We thought that understanding students’ opinions, beliefs and disparities could help us in bridging the research results on TBL with its actual implementation in our curricula at KAU in the future thus facilitating a smoother transition.
Thus to explore the experience of students in depth, a sample of students, six students, were invited (after obtaining their verbal consent) to participate in a single semi-structured interview in a focus group meeting setting. The overall objective of the focus group meeting, the time and place, the intended themes for discussion, and the method of recording were all discussed with members of the medical Education Department prior to involving the students.
A purposive sampling of students was conducted based on the students’ results in the TBL session. Students were divided into 3 categories according to their TBL session scores: high-scoring, average-scoring or low-scoring, and two students were chosen randomly from each of these categories. All students were invited verbally to attend the focus group discussion after describing to them the main objectives of the discussion.
The focus group discussion was conducted at the Medical Education Department in the presence of Dr Aliaa Alamoudi and Dr Lana Alshawwa. The aim of the focus group discussion was first explained to the students and included:
1) Knowing about their experience in TBL
2) Guidance in conducting the student survey
Verbal consent was taken from all students to record them. The semi-structured interview consisted of a set of pre-defined open-ended questions which addressed the students’ overall level of satisfaction with the TBL experience, the advantages and challenges of TBL in their opinion and whether the experience changed the way they studied.
Based on the students’ response to these pre-defined questions, the interviewers were able to diverge to pursue an idea in greater detail. Students were allowed to express their thoughts in Arabic or English. However, most of the interview was conducted in Arabic.
TBL Survey.
To evaluate all the Clinical Nutrition students’ (n=33) perspectives on their TBL experience a 34-question on-line survey with an additional three, open-ended questions was constructed based on themes that emerged from the earlier focus group meeting discussion. The survey questions were revised by local and national experts in medical education. To ensure the clarity of the survey content and to ensure its validity, it was first tested out by a small focus group of students before being distributed to all participants via email. The survey was divided into sections as described in Table 1.
Table 1.
Data and Statistical analysis
Exams scores were analysed and presented as mean ± SD using GraphPad Prism version 5.00 for Windows, GraphPad Software, La Jolla California USA. Students’ T test was used for testing the significance. A value of p<0.05 was taken as a cut-off value for significance. Qualitative data analysis was done through classification, determination of themes, and linking to present literature. The process began with identifying the main themes stemming from the research questions. A list of questions were prepared as guidance for the focus group discussion session. The basis of the questions were the research questions. Grounded theory analysis was conducted where data coding was accomplished in two stages. The first stage involved the generation of numerous category codes without limiting the number of codes where we listed the emerging ideas .Keywords that were frequently mentioned during the focus group discussions were also recorded and considered as indicators of emerging themes. The second stage involved focused coding. Where we combined and eliminated the coding categories identified in the first stage, during this step we were trying to find wider themes connecting the codes.