The Journal of Continuing Education in Nursing

Original Article 

Evaluation of Team-Based Learning to Increase Nurses' Knowledge of the Ventricular Assist Device

Carmelita Runyan, MSN, RN; Caroline Marshall, MLS; Harriet Aronow, PhD; Saisunee Vongkavivathanakul, MSN, RN; Laura Daniels, MSN, RN; Judy Currey, PhD; Bernice Coleman, PhD, ACNP-BC, FAHA, FAAN

Abstract

Ventricular assist devices (VAD) are used to extend life expectancy for patients with advanced heart failure. Approximately 102 hospitals nationwide have a VAD program, but the majority implant only a small number of devices each year. This low-volume and high-acuity patient population can create concerns for maintaining nursing knowledge skill levels. Nursing staff from a step-down telemetry floor in a large urban hospital completed an Individual Readiness Assessment Test to assess their knowledge and accuracy in the care of mechanical circulatory support patients using the Immediate Feedback Assessment Technique. The nurses were then assigned to small groups and worked as a team to complete the same test known as the Group Readiness Assessment Test. Study results suggest that team-based learning was effective in increasing knowledge of mechanical circulatory support. [J Contin Educ Nurs. 2021;52(1):13–20.]

Abstract

Ventricular assist devices (VAD) are used to extend life expectancy for patients with advanced heart failure. Approximately 102 hospitals nationwide have a VAD program, but the majority implant only a small number of devices each year. This low-volume and high-acuity patient population can create concerns for maintaining nursing knowledge skill levels. Nursing staff from a step-down telemetry floor in a large urban hospital completed an Individual Readiness Assessment Test to assess their knowledge and accuracy in the care of mechanical circulatory support patients using the Immediate Feedback Assessment Technique. The nurses were then assigned to small groups and worked as a team to complete the same test known as the Group Readiness Assessment Test. Study results suggest that team-based learning was effective in increasing knowledge of mechanical circulatory support. [J Contin Educ Nurs. 2021;52(1):13–20.]

Advanced end-stage heart failure remains a growing problem despite new drug therapies and interventions (Aissaoui et al., 2018; Buggey et al., 2015; Mitter & Yancy, 2017). Cardiac transplantation is currently the most effective treatment for advanced heart failure (Kransdorf et al., 2017; Mehra et al., 2016; Squiers et al., 2017); however, there are not enough suitable donors available with more than 4,000 patients waiting. Only 3,400 of those patients on the waiting list will receive a heart transplant (United Network for Organ Sharing, 2019). Over the past 10 years, mechanical circulatory support (MCS) programs have used the ventricular assist devices (VAD) as a bridging strategy to the unpredictable wait for a suitable organ cardiac transplantation (Akin et al., 2016; Feldman et al., 2013; Mancini & Colombo, 2015; Thunberg et al., 2010). These devices can be used as a bridge to heart transplantation or destination therapy for patients who do not meet heart transplant listing criteria but require support for the failing heart. Data from the Society for Heart and Lung Transplantation Mechanically Assisted Circulatory Support Registry on patients with continuous flow left ventricular assist devices (LVAD) (n = 13,038) have demonstrated a 1-year survival rate of 80% and a 3-year survival rate of 65% for this patient population (Kirklin et al., 2018).

Devices are now being placed in centers that may or may not have heart transplant programs as a treatment for end-stage heart failure. These devices require patients and caregivers to have thorough understanding of the device including how the device operates, need for a continuous power source, how to proficiently change power sources, and clinical care of dressing change to prevent infection. Nurses play a critical role in assisting patients and their families to adjust and understand their role as they traverse this clinical lifestyle challenge. These nurses must have a full understanding of the device, how to troubleshoot issues, and how to take care of the driveline, as well as expected adjustment of the patient–caregiver dyad to manage the device in the community setting. Preparing nurses to teach this content to patients and families poses challenges to both management and staff (Bond et al., 2004; Mancini & Colombo, 2015; Morales et al., 2000).

Learners should participate in activities involving real-life scenarios to retain knowledge and engage them in the critical thinking process (Currey et al., 2018; Oldland et al., 2017). The challenge was to find new instructional methods that would actively engage nurse learners and help nurses understand concepts for application in clinical situations. Therefore, team-based learning (TBL), a participatory teaching method, was chosen to facilitate staff nurses' retention of new knowledge (Bond et al., 2004; Dearnley et al., 2018)

This article evaluates the TBL approach to educating nurses to acquire the knowledge needed to prepare patients and family for discharge and reintegrating into their community life. This study aimed to determine whether the use of TBL was a viable approach to LVAD nursing education for content retention.

Rationale for Using TBL

Didactic lecture remains the most used teaching strategy. Fundamentally, the pace of the lecture is controlled by how fast the instructor delivers the content. Students often feel overwhelmed by the information presented. Students have fewer opportunities to apply knowledge during the learning experience, resulting in a lack of deep learning. This passive setting creates students who develop neither the interest nor the skills to learn and apply the information independently. Moreover, in didactic lectures, students play a nonparticipatory role in the learning process, encouraging mere memorization of content and discarding it when no longer needed (Alaagib et al., 2019; Di Leonardi, 2007; McRae et al., 2017).

TBL is emerging as an alternative. We chose the TBL approach to teach clinical nurses LVAD content because in practice, nurse often confer and depend on just-intime consultations with their colleagues for validation (Schmidt et al., 2019). TBL capitalizes on the value of group learning.

Patients with end-stage heart failure who have failed maximum medical management have complex needs. Their only option is a heart transplant; however, the waiting period is uncertain. The placement of an LVAD is often used to bridge end-stage heart failure patients who are awaiting a transplant until a suitable donor becomes available. Patients with LVADs represent a low-volume, high-acuity patient population. Nurses have a responsibility to insure the teaching, competency, and safety of the patient and family dyad (P-F dyad) for the return into the community. Nurses engage the P-F dyad in active participation in their care as they provide extensive discharge teaching to support patient compliance with treatment plan and prevention of a readmission (Bellumkonda & Jacoby, 2013; Kim et al., 2018) due to lack of education.

Efforts to improve transitions from an acute care setting back to the community have been studied extensively in heart failure populations (Colavecchia et al., 2017; Mathew & Thukha, 2018; Rezaee et al., 2016; Vesterlund et al., 2015). Staff nurses play a critical role in the discharge process by supporting the P-F dyad in acquiring new knowledge for preparing to return to the community. For patients on LVADs, the approach of one-to-one sessions is important to educating P-F dyads in the complex management needed to support integration back into their communities. These one-to-one education sessions can help prepare the P-F dyad for self-care management activities, including dressing changes, changing power sources from direct current (DC) to battery, managing the LVAD operating system, as well as managing changes in lifestyle, medications, diet, and intimacy (Casida et al., 2011; Kato et al., 2014; Marcuccilli & Casida, 2011; Weber, 2006). Nurses may not see many of these patients in any given year. Despite low volume, the teaching of these patients and families is critical to their survival and recovery. Nurses caring for these patients must feel empowered and confident with their understanding of all aspects of MCS in preparation for teaching P-F dyads to return to the community.

TBL Overview

Overview

The primary aim of TBL is to provide students with an engaging and active learning experience; enabling the learner to apply course content and concepts in a team setting and allowing students to teach and learn from each other. Students spend more time applying course material rather than simply listening to an instructor passively deliver content (Rezaee et al., 2016). Evidence exists that TBL has been successful in midwifery (Dearnley et al., 2018), teaching cardiac resuscitation skills in open heart surgery patients (Mathew & Thukha, 2018; McRae et al., 2017), physical therapy education (Macauley & Dirkes, 2017), and nursing students (Wong et al., 2017). Using a team approach to discussing questions or issues simulates what actually happens in practice in a clinical area. TBL can apply these active learning strategies with small (Kelly et al., 2005; McRae et al., 2017) or large (Kibble et al., 2016) groups. Earlier work related to TBL suggests that learners' attitudes improved regarding the value of working in teams and increased their engagement in the educational process (Levine et al., 2004; McRae et al., 2017). A similar approach is problem-based learning reported by Alaagib et al. (2019) and Chunta and Katrancha (2010). The authors described problem-based learning as a method that supports the learner in using critical thinking, self-directed knowledge acquisition, comfort in self-evaluation, and improvement in interprofessional communication skills (Chunta & Katrancha, 2010). Similar findings have been recently reported using TBL with physicians that support this early work (Al-Azri & Ratnapalan, 2014; Bodagh et al., 2017). These contrasting behaviors to traditional didactic classroom teaching change teaching from passive delivery of information from lecturer to active preparation and participation simulating actual real-life practice. TBL is similar to problem-based learning except that didactic lectures are replaced by case scenario, engaging staff in learning situations, and promoting critical thinking in a format that is similar to the work environment.

Elements of TBL

There are four elements of TBL: groups, accountability, feedback, and hands-on team assignments (Table 1). Prior to beginning TBL, participants are assigned readings to complete prior to the experience. They are asked to come prepared, having read the assigned content, and write down questions for clarity that may have arisen from their readings prior to attending the experience. These questions often can drive the discussion after individual and group testing. We allowed participants 2 weeks to complete the readings.

The Four Elements of Team-Based Learning (TBL)

Table 1:

The Four Elements of Team-Based Learning (TBL)

Formation of Groups. In preparing for group construction and participation, the leader must make sure these three areas are addressed:

  • Assign the members of the group to ensure there is adequate experience within the group to support a meaningful discussion and promote the completion of the assignment;
  • Construct the groups to avoid coalitions that may interfere with group dynamics; and
  • Support the development of a learning environment within the group.

Student Accountability for Individual and Group Work. Learners become accountable not only to the instructor but also to their fellow learners for the quality and quantity of their work as a group. Instructors monitor and facilitate group discussions to ensure that all members' opinions are heard and considered. The value of each member coming to the experience prepared can be observed in the group dynamics.

Immediate Student Feedback. A key component of TBL is the use of immediate feedback, which is important to learning, retaining new knowledge, and cultivating group dynamics (Currey et al., 2018). Epstein et al. (2002) found the use of immediate feedback promoted learner engagement, discovery, and retention of new knowledge (Oldland et al., 2017). First, learners independently complete the multiple choice questions with four options (A through D) on the test page provided by the instructor. This process of learning is known as the Individual Readiness Assessment Test (iRAT). Then, each group of learners discusses the same multiple choice questions one at a time. This process of learning is called the Group Readiness Assessment Test (gRAT). In this process, the TBL model provides learners during group test taking with immediate feedback once the group reaches consensus and chooses an answer using the Immediate Feedback Assessment Technique (IF-AT®) tool. The immediate feedback is gained by the revealing of a symbol on the IF-AT tool once the group scratches off their chosen answer (A, B, C, or D for each multiple choice question) on the IF-AT tool (Figure 1). If they have chosen a correct answer, they receive confirmation by the symbol.

Immediate Feedback Assessment Technique (IF-AT®) tool.

Figure 1.

Immediate Feedback Assessment Technique (IF-AT®) tool.

If the symbol is not revealed at first attempt, learners review and discuss their knowledge and scratch off an alternative option (A, B, C, or D). Each group of learners repeats the process until they find the correct answer by revealing the corresponding symbol. After groups have completed their test, it is given to the instructor and scored. The score is reduced with each unsuccessful scratch. Scores range from a low of zero for needing to scratch all four options prior to revealing the symbol to the highest score of four points if the group correctly revealed the symbol on the first attempt.

The impact of the gRAT on team development is immediate, powerful, and positive (Michaelsen et al., 2008). The iRAT for individual learning or gRAT for group learning are effective tools available for promoting both concept understanding and cohesiveness in learning teams, and they are an important element in successfully implementing TBL.

Finally, group participants are given a case study activity. This process facilitates team collaboration to solve the case. For our case presentation, we used LVAD patient management. After each group completed its discussion and consensus regarding the case, the leader called upon each team to discuss and defend their answers while the instructors provided feedback and clarified content issues.

Hands-On Group Practice to Further Promote Both Learning and Team Development. Within the group context of TBL learning, planning hands-on team assignments for groups can be optional and further provides experience using a team approach to discuss and solve issues while promoting healthy group interaction. (Alaagib et al., 2019; Currey et al., 2018; Michaelsen et al., 2008). At the completion of the case studies exercise, participants remained in their groups and convened at three clinical stations. The stations were chosen to provide hands-on experience with dressing changes, switching power from alternating current to DC, and reviewing the alarm state generated by the LVAD controller. This provided the nurse with real-time experience to enable a deeper teaching knowledge that could be transferred to the both the patient and family in a teaching environment. Staff were asked to complete a brief TBL evaluation regarding their experience using a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree). Data were analyzed using percent reported according to the Likert scale categories.

Study Setting and Participants

Study Setting

This study was conducted in a 977-bed hospital that implants approximately 40 LVAD patients per year and treats more than 50 patients in the community postdis-charge. On the step-down unit, staff nurses assist the MCS coordinators in preparing patients and families with education in preparation for transition to home. Because these devices are low volume and high acuity, there is always a challenge in supporting staff nurse education and maintaining competencies.

Participants

Sixteen cardiac surgical nurses, ages ranging from 25 to 60 years with more than 1 year of experience, underwent the TBL educational approach. All participants had previous education, training, and experience caring for and teaching patients and families with an LVAD. Participants in this study were selected by their nurse manager to attend the class based on their availability.

Protocol

One week prior to class, participants were given required reading to complete before coming to the program. On the day of the class, the participants were given a 10-question test and 10 minutes to complete their answers using the iRAT. The iRAT was designed to determine participants' readiness to apply the core concepts learned from the assigned readings. After individuals completed their iRAT, they turned in their test sheet prior to the next task. Participants were assigned to groups of two to three members making a total of six groups. Participants were asked to retake the same test, the gRAT. During this phase, participants were expected to read the question out loud, discuss the answer to each question, and arrive at a consensus group answer as a team. One member would scratch off the answer on the gRAT tool. If the feedback displayed a symbol indicating that the answer was correct, the team moved on to the next question. If not, the team discussed the question again and repeated the process until the feedback symbol appeared indicating the answer was correct. While participants were in groups retaking their gRAT test, their individual scores on the iRAT were being graded by the instructor.

Evaluation

During the TBL experience, participants completed the iRAT test sheets individually and the gRAT in groups.

Continuous data scored were calculated from these tools. Participants were also asked to complete a brief survey regarding their impressions of the TBL experience at the completion of the day program. Data were gathered from the survey using Likert scales and summed into a continuous score. No data were collected from the instructors regarding their experience with the TBL program.

Analysis

Data were generated from participants' test taking alone (iRAT) and participants generating a group answer (gRAT). Coded data were checked for accuracy by the researcher manually checking a random 10% of the data for errors. Prior to analysis, the assumptions of independence and sample distribution normality were verified. A paired-sample t test using SPSS® (version 24) was used to compare differences in the mean scores between nurses testing alone or in a group. Significance was set at p = .05. Within each group, the individual participant iRAT scores from Time 1 were averaged and compared with the group average gRAT Time 2 score. This study used the Standard for Quality Improvement Reporting Excellence (SQUIRE 2.0) as the framework for project.

Results

Time 1 iRAT scores ranged from 38 to 45, with a mean of 42.13 (SD = 2.961). Data were slightly skewed but still within the assumption of normal distribution. Time 2 gRAT scores ranged from 45 to 50, with a mean of 48.17 (SD = 1.835) and were also normally distributed. There was a significant increase in group mean scores on the gRAT (48.17, SD = 1.835) compared with individual iRAT scores (M = 42.13, SD = 2.961), t = 4.997, p = .004. Nurses completing the iRAT alone demonstrated a statistically significant higher score on gRAT with the benefit of group discussion.

Discussion

The TBL approach was used to reinforce the education of staff nurses caring for patients with an LVAD supporting the failing ventricle. This educational approach allowed nursing staff with previous knowledge of caring for LVAD patients to gain knowledge and skills benefiting from the discussion and collaboration within groups. Nurses are the primary teacher for the LVAD P-F dyads in preparing them for assuming this high-tech role of balancing care and technology within the community setting. Using a TBL approach provided nurses with an opportunity to gain further confidence through self-preparation and nurse-to-nurse collaboration facilitated by the instructor. Similar findings of improved group scores were found in teaching trauma physicians (Cremerius et al., 2020). This study provides further evidence that TBL can be used as a viable teaching method for clinicians in hospital settings and that a team approach to learning can provide a rich learning environment. (Considine et al., 2014; Considine et al., 2013). These findings also provide evidence that TBL can be used in a refresher training of clinical context for a highly specialized patient population (Currey et al., 2018; Oldland et al., 2017).

We observed additional benefits associated with TBL. Participants were engaged and became problem-centered learners. The instructors who taught the class became facilitators of learning using their expertise to clarify content, instead of providing content in a didactic lecture mode from which learners may be distracted and not continuously engaging. The iRAT assisted the instructors in identifying learners who were having difficulty understanding course content thus allowing for focused support and assistance during the experience. During the gRAT and case study analysis, the nurses learned from each other, taught each other, and learned to solve problems as a team. By solving problems as a team, participants learned to be respectful of others' opinions and to accept responsibility for shared decisions. Learners expressed high levels of satisfaction with TBL activities as evidenced by high course evaluations. In addition, anecdotally, staff who attended the TBL experience shared their experience with other nurses in the units who had not attended, and the others expressed enthusiasm to participate in the future (Table 2).

Team-Based Learning (TBL) Participant End-of-Class Experience Survey (N = 16)

Table 2:

Team-Based Learning (TBL) Participant End-of-Class Experience Survey (N = 16)

Challenges existed in implementing TBL. The construction of the class schedule was challenging, as the instructors had to predict the amount of time required for completion of iRAT and gRAT. There was anxiety on the part of the staff as they prepared to attend the new class format. Instructors spent time with staff to ensure they had the materials needed, clarify course contents, lead group discussion of case studies, and provide adequate time for feedback and hands-on training. During the implementation, the researchers also found that the participants did not have enough time to complete the assigned readings prior to the class meeting. We found that setting learner expectations was key for the success of this learning method.

Limitations

This study had a small sample size of 16 participants and learners. The lack of representation of a larger population may limit generalizability. There was no comparison group to measure the impact of TBL compared with usual didactic teaching environment. We modified the traditional TBL approach, and thus replication using this modified TBL approach would provide insight into its value and application in the clinical setting moving forward. No data were collected regarding the impression of the instructors in this TBL experience. Data should be collected regarding the impact of TBL methods related to the time needed to prepare for the experience and instructors' impression of group facilitation and preparing for aspects of the program.

Implications

Although the study sample was small, the data suggest that the TBL approach in preparing cardiac nurses to teach patients and families is encouraging. Nursing competency, accurate assessment of MCS patients, and confidence to teach the P-F dyads is critical to early convalescence and prevention of complications after discharge from the hospital. Designing education that is engaging and supports self-confidence of nurses is important to patient safety and outcomes. Nurses reported that TBL fostered collaboration during the group experience that was similar to their practice in the clinical setting. Based on the learning scores and feedback from the nurses in this study, TBL has the potential to be adopted by hospital educators as an innovative teaching strategy versus the standard didactic approach.

Conclusion

In this single-site study, TBL was a useful educational strategy for enhancing LVAD knowledge among specialized nurses. Participants rated the group experience higher than the test taken alone suggesting the positive impact of a team approach to learning, a known feature of TBL. Our study is a first of its kind using TBL as a teaching mechanism for MCS teaching. Although the results are encouraging, future studies are needed to compare traditional didactic approach to TBL.

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The Four Elements of Team-Based Learning (TBL)

ElementElement TitleElement Content
Pre-TBL experience

Learner is given material to read with instructions to seek our leaders with questions prior to the TBL experience.

We disseminated our teaching material 2 weeks prior to the TBL experience.

Element 1Formation of groups

Within groups, we ensured there was one nurse with at least 2 years of experience.

Instructors should avoid coalitions that may interfere with group dynamics when assigning groups

Instructors are assigned to the groups to promote engagement of all group members.

Element 2Student accountability for individual and group work

Participants were expected to read material prior to the TBL experience.

Within groups, all participants are expected to discuss and have opinions on the answer being chosen.

Instructors role is to ensure all participants are engaged for a balanced discussion prior to the selection of the group answer.

Element 3Immediate student feedback

Each participant completes testing alone. These tests were then graded by the instructors.

Participants then were divided into groups, given the same test, al-lowed to discuss answers, then each group chose their group response by scratching one answer on the immediate feedback assessment card

If the star appeared, the group moved on to the next question. If nostar appeared, the group repeated the process until they gain positive feedback, as demonstrated by the appearance of the star.

Element 4Assignments that promote both learning and team development

Postgroup test taking, groups discussed case studies and shared their answers with the entire cohort.

Participants determined the didactic content presented our program based upon the knowledge deficits in the group testing experience.

We developed three stations that were identified by the participants as area requiring more hands-on experience: Dressing change, Changing power sources, Response to emergency alarms.

Participants remained in their testing groups and moved between station with the same instructors.

Team-Based Learning (TBL) Participant End-of-Class Experience Survey (N = 16)

Survey QuestionDisagreeAgreeStrongly Agree
1. Two weeks was enough time to complete the reading prior to the TBL experience.10 (62.5%)6 (37.5%)
2. I felt prepared to take the initial class test.16 (100%)
3. Participation in group discussion and testing helped me further understand the content of the questions.16 (100%)
4. I found the TBL learning experience more informative than lectures alone.16 (100%)
5. The hands-on experience gave me confidence to teach my patient and family for discharge home.16 (100%)
6. The TBL experience helped me to gain confidence in understanding the left ventricular assist device.16 (100%)
7. I would look forward to attending TBL educational classes approach in the future.2 (12.5%)14 (87.5%)
Authors

Ms. Runyan is Lead, Mechanical Circulatory Support Program, Ms. Marshall is Senior Medical Librarian, Dr. Aronow is Research Scientist IV, Nursing Research Department, Brawerman Nursing Institute, Ms. Vongkavivathanakul is Assistant Nurse Manager, Ms. Daniels is Assistant Nurse Manager, Cedars-Sinai Medical Center, Los Angeles, California. Dr. Currey is Professor of Nursing and Director, Active Learning, Deakin University, School of Nursing and Midwifery, Victoria, Australia. Dr. Coleman is Director, Nursing Research and Performance and Improvement, Cedars-Sinai Medical Center, Los Angeles, California.

The authors have disclosed no conflicts of interest, financial or otherwise.

Address correspondence to Bernice Coleman, PhD, ANCP-BC, FAHA, FAAN, Director, Nursing Research and Performance and Improvement, Cedars-Sinai Medical Center, Brawerman Nursing Institute, 8700 Beverly Blvd. North Tower, Suite 2021, Room 2020, Los Angeles, CA 90048; email: Bernice.coleman@cshs.org.

Received: November 05, 2019
Accepted: June 17, 2020

10.3928/00220124-20201215-06

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