In the field of health sciences where a large compendium of research and knowledge exists yet data and interpretation rapidly changes, you often feel pressured to deliver as much content as time allows. The lecture-based classroom that often results from this pressure places students into a passive mode, and while you are teaching, it is not always clear whether the students are learning. One pedagogically sound approach that engages students in meaningful work and encourages them to develop skills applicable to their profession is team-based learning (TBL). This approach uses group work as a strategy to teach course content. The majority of class time is spent in groups in which students actively solve problems that they will likely face in the future of their respective fields.
Team-based learning (TBL) is particularly effective in health professions education where opportunities to learn and practice problem solving and application of core concepts are critical to students. This section will introduce the concept of team-based learning in the health professions and provide suggestions on how to create an effective team-based environment.
About Team-Based Learning
Team-based learning emerged in the 1970s as a way to engage students in large classes. Since then, it has been applied across all the disciplines and has achieved a strong foothold in the health professions education community. Team-based learning promotes the real-world application of skills and holds students accountable for their own learning.
When properly designed, a team-based learning approach achieves a high level of student engagement that is not possible in an instructor-centered learning environment. The critical difference between team-based learning and group work is that the construction and operation of the team is a central part of the learning process in team-based learning. Students are not only learning the material and contributing to the construction of a group project. They are also developing problem-solving and teamwork skills.
TBL in Health Professions Education
Team-based learning has proven to be effective in getting students to assimilate course content and in preparing them for future professional decision-making, and its adoption has spread to many disciplines, including health professions education. Those who have adopted TBL in health professions programs find it particularly suitable for these fields of study because students are expected to know large amounts of information, demonstrate that they know a variety of facts, and ultimately apply their newly acquired information. In addition, students must be able to show their facility with problem-solving and decision-making in the context of working with other health care professionals, educating their own patients, and demonstrating the attitudes and skills of successful health care professionals. With its readiness assurance process and the focus on group activity and decision-making, the TBL approach provides this type of learning environment for students and the group work prepares them to develop the competencies of working as a member of a self-directed team (Parmelee, 2008b).
- Increases student engagement
- Promotes the development of skills necessary for effective teamwork
- Develops skills in collaboration and problem solving which can be applied in the clinical setting
- Encourages higher-order thinking
- Provides visible measures of student learning
- Content needs to be restructured into team-based projects
- Facilitation methods can be uncomfortable if you are new to the process
Developing and Facilitating a Team-Based Learning Environment
Michaelsen and Sweet (2008b) maintain that there are specific elements essential for groups to develop into high-functioning learning teams.
Create teams to promote inquiry
The careful construction of the team is at the core of an effective team-based learning experience. The ideal team size is 5-7 members, with static membership across the semester. The teams should be chosen and managed by you to avoid sub-groups or cliques. In optimizing conditions for group cohesion, create groups with a diverse (in terms of background, experience, ethnicity, etc.) set of members as possible, avoid placing two or more students who have some previously established relationship in the same group, and keep the same groups throughout the entire semester to allow self-directed teams to develop over time.
If one focus of the assignment is to develop collaborative skills, teams should be encouraged to collectively determine solutions to problems; i.e., you should discourage dividing the work among individual team members. Since a primary goal of team-based work is to develop teamwork skills, the functional relationship that develops among the team members is as important as the material being discussed.
For more details, take a look at this page from the Team-Based Learning Collaborative’s site: Team Formation for TBL.
Identify opportunities for team-based assignments
While a team-based assignment can be created from any topic, they function best when they engage students in multi-faceted problem-solving and team-building exercises. They should involve skills or procedures that students will need to apply in the clinical setting and ask students to incorporate material learned in lecture or in labs. Examples of team-based assignments in health professions education include diagnosis, application of clinical knowledge to determine the appropriate treatment or intervention, and prediction of possible patient outcomes.
The most successful TBL assignments are those that require students to apply course themes and concepts in their decision-making process and that are simple in output. The goal is to get students involved in unpacking complex issues during the group activity and to be able to focus on a simple way of delivering their decision and rationale. This is why long research papers (rather complex outputs) are strongly discouraged as methods of assessing group work. TBL instructors recommend following the 4 S’s in designing TBL assignments. These include:
- Create group assignments that are significant to students.
- All teams should work on the same assignment problem.
- Students should make a specific choice in response to the problem.
- Students report their choices at the same time.
(Michaelsen & Sweet, 2008a, p. 20)
Create questions/problems/scenarios to engage students
After identifying an authentic situation that realistically engages students in a team-based assignment, create a set of questions or scenarios that students will use to explore the material. When creating questions or problems for the teams, consider ways to engage students and maintain authenticity. The questions should promote exploration of various possible answers and be tied to course outcomes. Ideally, the assignments should engage students with the material presented in lecture. That is, after passively receiving course material, the students should engage with the material through the team-based work. Unlike case-based assignments, team-based assignments can focus on smaller-scale problem sets and be interspersed throughout a lecture or a lab.
Given a case history or set of patient-related examination findings:
- Recommend a process for determining the patient’s diagnosis and treatment needs
- Recommend additional tests or examinations to be conducted
- Determine the most probable diagnosis
- Devise and explain a treatment plan
- Predict likely outcomes from a given intervention(s) or treatment(s)
- Recommend a process of determining the best course of action for the patient’s continuing care
Frequent and immediate feedback positively influences student learning and contributes to group development.
Make students accountable
For a team-based learning experience to succeed, all students must be prepared to engage with the material and each other. Students must be held accountable for the quality of their preparation for in-class activities, team members need to be accountable to one another through peer assessments, and teams must be accountable to high quality results. The latter can be accomplished by designing team assignments so that their product can be easily and frequently compared to that of other teams.
The Readiness Assurance Process
Students must go beyond simply scanning to familiarize themselves with course content. They must study and absorb assigned course materials for each unit of the course. To prepare for group activities and ensure accountability, students are tested in what is called the Readiness Assurance Process, also known as RAP. They must comprehend course content before coming to class because the majority of time in class is spent applying major concepts from their readings.
To ready students for the in-class assignments and ensure that individuals are assessed for their contribution, consider the following steps using The Readiness Assurance Process (RAP):
- Create pre-class worksheets that focus students’ reading on the central issues related to the assignment.
- Assess student readiness through graded pre-class quizzes of key concepts and related course material (RAP).
- While grading the individual quizzes, have the students take quiz again in teams. During the team test, students must come to a consensus on the answer to each test question, thus requiring students to argue for their correct responses.
- Following the test, give immediate feedback to the questions, and lecture for a brief period of time. Provide both individual and team feedback on pre-class quizzes to establish a baseline of understanding. Allow teams to justify alternate answers.
- Assign team-based question/problem/scenario.
- After a set period of time, teams announce their best answer/approach.
- If discrepancies exist among teams, teams defend their positions.
- Wrap up the discussion by emphasizing application of core concepts.
- Have students grade their individual contribution to the team effort. Incorporate student self-assessment into your assessment.
- Grade the work of the team based on process, effort, and results. Be sure to include supportive feedback that encourages teams to continue to work hard.
- Have the teams justify their results to the entire class.
- Students’ final grades are based on both individual and team performance.
This concise, focused process is meant to clear up misunderstandings in the course material and allow students to develop arguments for any answer they would like to appeal. Once this process is complete, the majority of class time is spent applying course content through group activity and assignments (Michaelsen & Sweet, 2008).
While the traditional team-based approach was designed for the standard face-to-face classroom, team-based learning can be employed in any modality. How does team-based learning translate into the online environment? With time to plan ahead and design a instructionally sound course, those who have (Palsolé & Awalt, 2008) implemented TBL online have done so with success. Listed below is information on how to implement and design TBL in an online course. The extensions apply the same general concepts outlined for face-to-face team-based learning to technology-enhanced learning environments, either web enhanced, blended/hybrid, or fully online.
Group discussion forums and activities
In a technology-enhanced classroom, you can assign different teams to groups within the learning management system. The groups should be private and only visible to group members. After working together for a set period of time, an individual group member can post to a whole-class discussion forum and describe and defend the position of the group. Other online group activities:
- Assigning appropriate textbook readings and other resources including those that are online.
- Posting assignments to common discussion forum.
- Teams discussing via the group discussion board and coming to a consensus.
- Teams developing assignment products on a wiki, shared Google docs, or use of other collaborative tools.
- Team leader posting assignments to the Dropbox and uploading assignments to discussion forum along with the list of team assignment discussions.
- Conducting peer assessments.
- Assigning reflective assignments to synthesize learning and experience. This activity can also yield feedback for your future course planning and revisions.
Online quizzes (Online Readiness Assurance Process)
A critical factor in the success of team-based learning is learner readiness. Since the classroom time is spent working through problems in teams, each individual team member must be prepared to participate. In a web-enhanced, blended, or online course, online quizzes can be used to assess learner readiness. The quizzes can be used as a graded assessment item or a self-assessment on the part of the student. Whether they are graded or not, the quizzes should encourage students to research the correct answer. To apply the Readiness Assurance Process online:
- Use the Quiz tool in D2L to give the individual readiness tests to each student.
- Once complete, open the course discussion forum to allow teams to discuss answers to test items for a couple of days.
- Assign a team leader to answer the team readiness assurance test based on the answers arrived at through consensus on the discussion topic.
- Assign a team reporter to post a summary of the discussion on common discussion forum.
- Both you and students post feedback on common discussion forum.
- Post a mini lecture in response to student discussion posts, clearing up misunderstandings as evidenced by discussion threads.
- Peer assessments are conducted.
- Repeat the process about five times during the semester for each unit of study.
While most online courses (or online portions of blended courses) are asynchronous (students log on at different times), the synchronous or live classroom, like Adobe Connect, can be employed in a team-based learning environment to provide opportunities for students to communicate in real-time regardless of their physical location.
In this case, the students should be able to determine the best time for meeting online to ensure the flexibility of online learning is preserved. Individual groups should then post their answers to the problem in an online discussion forum. Monitor the whole-class discussion forum and encourage teams to justify their positions.
Building Learning Community, Fostering Team Cohesion, and Managing Expectations
As with any online environment, best practice recommends you build a learning community and manage student expectations. This is also the case for a new teaching strategy. In creating a learning community that relies heavily on group dynamics, be sure to foster team cohesion by creating introduction posts. Some even recommend that TBL students share their strengths and weaknesses with one another in the introductions (Palsolé & Awalt, p. 89). In this way, students can think about ways they can support one another in the learning process and leverage each other’s strengths in the group activities. Having students create team contracts and establish their own strategy for working with one another creates the expectation that each student contributes to the success of the team’s learning. Asking students to offer thoughtful comments on each other’s posts not only ensures that each member’s ideas are being taken into account, but also offers fresh perspectives and approaches to problem-solving. Spending a fair amount of time and energy in reading and composing discussion threads implies the importance of this tool as a catalyst for learning and each student’s contribution.
In terms of managing expectations, explain the benefits of TBL to students and set out the exact procedures for how TBL will unfold in the course in order to get students on board with the new strategy. Remember, students mainly take online courses for the flexibility they offer, and it may be unrealistic to ask teams to find a mutually available time for them to complete group activities. This implies a re-design of this portion of TBL from the face-to-face version. The asynchronous nature of online courses also necessitates more time for student-student exchange and feedback on discussion posts and assignment contributions. While the success of TBL relies on immediate feedback, it does not necessarily mean it must be instantaneous (Palsolé & Awalt, 2008).
Burgess, A. (2014). Applying Established Guidelines to Team-Based Learning Programs in Medical Schools: A Systematic Review. Academic Medicine, 89(4), 678-678.
Michaelsen, L.K., Knight, A.B., & Fink, L.D. (2004). Team-Based Learning: A transformative use of small groups in college teaching. Sterling, VA: Sylus Publishing.
Michaelsen, Larry K., Parmelee, Dean X., McMahon, Kathryn K., & Levine, Ruth E. (2008). Team-Based Learning for Health Professions Education: A Guide to Using Small Groups for Improving Learning. Sterling, VA: Sylus Publishing. (available for borrowing from the Teaching Resources Library)
Michaelsen, Larry K. and Sweet, Michael (2008). “The Essential Elements of Team-Based Learning,” New Directions for Teaching and Learning, no. 116. http://medsci.indiana.edu/c602web/tbl/reading/michaelsen.pdf [last accessed 7 July 2012].
Michaelsen, L. K., & Sweet, M. (2008a). The Essential Elements of Team-Based Learning. In L. Michaelsen, M. Sweet, & D. Parmelee (Eds.), Team-Based Learning: Small-Group Learning’s Next Big Step. (7-27). San-Francisco, CA: Jossey-Bass.
Michaelsen, L.K., & Sweet, M. (2008b). Fundamental principles and practices of team-based learning. In L.K. Michaelsen, D.X. Parmelee, K.K. McMahon, & R.E. Levine (Eds.), Team-based learning for health professions education (pp. 9-34). Sterling, VA: Stylus Publishing.
Palsolé, S., & Awalt, C. (2008). Team-Based Learning in Asynchronous Online Settings. In L. Michaelsen, M. Sweet, & D. Parmelee (Eds.), Team-Based Learning :Small-Group Learning’s Next Big Step. (87-95). San-Francisco, CA: Jossey-Bass.
Searle, N.S., et al. (2003). “Team learning in medical education: Initial experiences at ten institutions,” Academic Medicine, 78, 55-58.
Team-Based Learning Collaborative