Dr Aamir Magzoub
Associate Professor of Physiology, Department of Physiology,
College of Medicine, Najran University, Kingdom of Saudi Arabia

Team-based learning (TBL) is a student-centred and instructor directed teaching strategy for small-group active learning. TBL enables students to apply conceptual knowledge through a sequence of events, including individual work, teamwork, and immediate feedback. The TBL approach underpins group learning and has many proven advantages for the students in terms of knowledge, skills, and attitude domains (Sharma et al., 2017; Kibble et al., 2016; Allen et al., 2013).

Launching the TBL teaching strategy

In alignment with the new trend in medical education to shift from teacher-centred to student-centred education and early exposure of medical students to the clinical setting, we decided to introduce the TBL strategy for physiology teaching at the College of Medicine, Najran University, Saudi Arabia in the academic year 2019-2020.

The TBL strategy was chosen specifically because of the previously mentioned benefits for students. TBL also has benefits for both the TBL instructors and the college: it provides motivation and a greater opportunity for instructors to interact with students, particularly in large class settings (as opposed to passive one-way lectures), more reflection, immediate feedback, and high satisfaction for achieving of the learning objectives. For the college, TBL requires no extra facilities, and only one staff member can conduct the TBL session for all TBL groups in one classroom.

We started by interactive training workshops on the TBL for both the faculty and the preclinical phase medical students. TBL physiology topics were prepared by the physiology department, approved by the medical education department, and then injected into the course specifications of the preclinical phase courses. A TBL practical guide was distributed to facilitate easy application of the new teaching strategy, and a student feedback questionnaire was prepared for evaluation of the students’ perception of TBL.

TBL process

TBL is implemented in three phases: preclass preparation, in-class readiness assurance, and the application of course concepts (Table 1). In the preclass phase (phase I), students receive suitable learning material accompanied by learning outcomes on a specific physiology topic, e.g. cardiac cycle and heart murmurs. Students study the learning materials individually in preparation for the TBL in-class session.

Phase II includes an individual readiness assurance test (iRAT), team readiness assurance test (tRAT), feedback and clarification, and team appeals. The iRAT contains multiple-choice questions (MCQs) with special construction (i.e. MCQs that promote discussion, critical thinking, and teamwork). The iRAT is completed in the classroom under exam-like conditions. The tRAT is the same as the iRAT test but is discussed in groups (e.g. 5 groups for 35 students’ cohort). In the same classroom, students arrange themselves in teams, however is comfortable for them. The group members are known before the in-class TBL session, i.e. determined by the staff at the start of the course. The students receive the tRAT with ONE answer sheet. They go over the test items and come up with ONE key answer for each item question. An immediate feedback answer sheet (IF-AT) is used to improve group dynamics, group discussion, and item responses by providing immediate feedback that assesses their knowledge. Students scratch off a thin opaque covering to show their agreed-upon answer choice (A, B, C, D, or E) for each question in the IF-AT. The correct answer reveals a star under the scratched choice and incorrect options are blank. When students get a blank response, they go back and discuss the question again until they agree on a new option. The score awarded in each question is determined by the number of attempts taken to reveal the star. Furthermore, the instructor provides feedback and clarifies any ambiguities regarding the tRAT. At this stage of phase two, the students have the right to appeal (in writing), but they must all agree on their appeal (i.e. a group appeal).

In phase III, students receive group assignments in the form of real-life case scenarios they will encounter in the clinical stage to integrate the pre-learned knowledge with ONE answer sheet. The application assignments follow a specific rule (Table 1). The students’ group learning is evident in this phase as they discuss and analyse the case scenarios and integrate their previously learnt knowledge to solve problems. A class discussion with the TBL instructor to clarify any issues relevant to the application assignments will take place once more.

Essential principles for successful TBL

The main principles for the effective working of TBL include: 1) Properly formed and managed team groups: Each team group should include 5-7 members; they should exhibit diversity in capabilities and academic levels. Team groups are assigned at the start of the semester and continue throughout to enhance team-building. 2) Student accountability: Students should be accountable for the quality of the pre-class preparation and show active engagement throughout the in-class teamwork. 3)Well-constructed assignments: Questions in the tRAT should promote discussion, active learning and follow sound question writing techniques, e.g. questions that seek clarification, reasoning, and consequences. Team assignments should include reallife problems and should promote group cohesiveness and team-building. 4) Frequent and immediate feedback: Timely feedback by the expert instructor is crucial during group and class discussions. It enables members to quickly correct their misconceptions of the subject matter.

TBL assessment

In all programme modules that contain TBL, the TBL sessions have a 10% weight in the final summative assessment. TBL sessions are assessed through: 1) Results of the iRAT (60%), 2) Results of the tRAT (20%), and 3) Results of the application assignments (20%). Peer evaluation (5%–10%) can be included by using special methods such as Michaelsen and Fink’s, in which each student rates his

or her other group members based on their contribution to learning acquisition and the team performance (Michaelsen et al., 2008). If peer evaluation is included, the group work (tRAT & application assignments) is worth 30%–35%.

The score from the iRAT is weighted the highest for two reasons: firstly, to encourage preparation in the pre-class phase and the mastering of the learning material; and secondly to buffer and balance the results of the tRAT and application assignment because all students in the same group receive the same mark.

TBL outcome

According to the student feedback questionnaire, most students were satisfied with the new teaching strategy with nearly similar response ratios in the various preclinical system-based courses (Fig.1). The TBL teaching strategy underpinned group learning of physiology in the preclinical phase and enhanced students’ knowledge, skills, and attitude domains. In the knowledge domain, students can better retain and retrieve information; they also learned basic physiological concepts and how to apply them in case-based assignments. In the skill domain, students acquired critical thinking and reasoning; they could accomplish difficult intellectual tasks. In the attitude domain, TBL helped the development of teamwork and professionalism. The TBL results were consistent with the other summative assessment tools. The TBL instructors’ survey showed high satisfaction with the application process and gave key notes for future improvement, such as including a clinical instructor in the TBL sessions with more clinical application.

The take-home message

TBL is an effective teaching and learning method for physiology, integrating it with clinical disciplines. The learning process in TBL includes three levels: 1) student individual level (pre-class preparation); 2) student group level (in-class tasks); and 3) TBL instructor level (clarification of difficult concepts). The rationale for using TBL is that it is a good interactive alternative to passive lectures, requires no extra facilities or staff, and helps students acquire knowledge and develop interpersonal skills and professionalism. Successful application of TBL requires properly formed and managed groups, student accountability, team assignments that promote learning and team building, and immediate feedback.

References

Allen RE et al. (2013). Team-based learning in US colleges and schools of pharmacy. American Journal of Pharmaceutical Education 77(6), 115. https://doi.org/10.5688/ajpe776115

Kibble JD et al. (2016). Team-based learning in large enrollment classes. Advances in Physiology Education,40(4), 435–442. https://doi.org/10.1152/advan.00095.2016

Michaelsen LK et al. (2008). Peer evaluation in Team- Based Learning. In: Team-Based Learning for health professions education. 1st edn., 112-113. Stylus publishers.

Sharma A et al. (2017). Understanding the early effects of team-based learning on student accountability and engagement using a three session TBL pilot. Currents in Pharmacy Teaching and Learning 9(5), 802–807. https://doi.org/10.1016/j.cptl.2017.05.024