The rapidly evolving health care environment has created a need for dramatic changes in nursing practice. In response to this need, nursing education must adjust with equally transformative innovations. Not only do nurse educators need to keep up with the ever-changing health care environment, they also must cover large amounts of course content, teach students how to clinically reason through the development and implementation of realistic patient-care scenarios, and ensure that students develop collaboration skills (Fink & Parmelee, 2008). In addition, transformation of nursing education is recommended by national organizations such as the National Council of State Boards of Nursing, the National League for Nursing, and the American Association of Colleges of Nursing. A recent publication suggests that nursing curricula and educational practices must undergo radical transformation (Benner, Sutphen, Leonard, & Day, 2010). Benner et al. (2010) asserted that “new nurses need to be prepared to practice safely, accurately, and compassionately, in varied settings, where knowledge and innovation increase at an astonishing rate” (p. 1), and this must occur while often working in less than desirable and chaotic circumstances.
It is not surprising that based on these calls for transformation and reformation of nursing education, many educators are seeking alternative, student-centered teaching and learning strategies that will assist in meeting the many challenges of nursing education. Team-based learning (TBL) is a student-centered, structured teaching strategy that provides students with opportunities to develop interpersonal and teamwork skills (Parmelee, 2008). The purpose of this article is to provide the background on TBL and to demonstrate the implementation of TBL in a traditionally lecture-based maternal–newborn nursing course.
Background of TBL
Team-based learning was developed in the late 1970s by Dr. Larry Michaelsen (Fink & Parmelee, 2008; Mennenga & Smyer, 2010). It was designed with the intent of actively engaging students in business classes with large student enrollment. However, TBL can be used in both large and small classes with similar positive results. Although health care education was slow to adopt TBL, it did so for the same reason as other fields such as business and accounting: it provides students with opportunities to problem solve and work with their peers, which are real-life experiences in either profession (Opdecam & Everaert, 2012).
Courses using this instructional design focus on a three-phase model to impart course material (Clark, Nguyen, Bray, & Levine, 2008; Mennenga & Smyer, 2010). For each content unit within the course, students participate in the following phases: (a) preclass preparation, (b) a readiness assurance process, and (c) the application of course concepts. The first phase in TBL involves preclass preparation, which may include reading assignments, online activities, or other assignments at the instructor’s discretion. After students enter the classroom, the second phase—the readiness assurance process—occurs. Students begin by taking an Individual Readiness Assurance Test (IRAT), which is a closed-book, multiple choice quiz based on the preclass assignments. After completing the IRAT, the students work in preassigned teams to complete a Group Readiness Assurance Test (GRAT). This is the same closed-book quiz as the IRAT; however, students are able to discuss the items as a team and come to a consensus on the answers. After completion of the GRAT, the teams work on application exercises, which are designed to build on the concepts learned in the preclass assignments (Michaelsen & Sweet, 2008b).
Research supporting the use of TBL reports improvement in student preparation (Clark et al., 2008; Dana, 2007), student engagement (Clark et al., 2008; Mennenga & Smyer, 2010), accountability (McInerney & Fink, 2003), teamwork (Clark et al., 2008), and student outcomes (Clark et al., 2008; McInerney & Fink, 2003). Team-based learning challenges students to apply knowledge within strategically developed teams (Michaelsen & Sweet, 2008a). Although traditional lecture format allows for the transmission of a large amount of information in a short period of time, it lacks student engagement and the opportunity to apply the information. Students often memorize content to regurgitate it on an examination but fail to proceed to a deeper level of learning (Di Leonardi, 2007; Janssen, Skeen, Schutt, & McMahon, 2008; Jones, 2007). Although TBL has been used as an instructional design in multiple disciplines of study, including accounting, business, psychiatry, and medicine, it is a relatively new pedagogy to nursing education (Mennenga & Smyer, 2010).
Implementation of TBL in a Maternal–Newborn Nursing Course
Much like Larry Michaelsen, the authors faced large class enrollments of 80 students each semester and were motivated to transform the passive learning environment of a lecture-based maternal–newborn nursing course. This course was designed to achieve three credits of lecture and two credits of clinical experience and had traditionally been conducted as lecture presentations with accompanying PowerPoint® slides for each weekly 3-hour class session. Traditionally, students sat in a large, darkened classroom and focused on typing notes into laptop computers, with occasional conversations for case study discussion. Overall, there was minimal opportunity for any meaningful student interaction during the class sessions. With a goal of greater student engagement and accountability for learning, the faculty selected the TBL strategy as a means to transform the classroom environment and the learning milieu. In comparison with a traditional lecture-based format, where the teacher is the source of information, TBL engages students in self-managed teams that process the course content through focused learning activities.
Nine units of theory content in the course Nursing Care of the Childbearing Family did not change with the introduction of TBL. Two faculty members split the responsibility for the delivery and testing of course subject matter. The course was reformatted for TBL by developing required preclass reading assignments of two to three chapters from the assigned text, plus accessing one to two additional Web sites or journal publications to supplement the textbook in preparation for each week’s 3-hour block of class time. Instructor-authored reading guides and outlines were incorporated into the course’s online resources for student access as a means to guide student reading for key concepts. Each instructor developed activities and assignments for team-based student interactions, which guided students in the application of course content (Table). This is consistent with Michaelsen’s and Sweet’s (2008b) process in that “the instructor’s primary role shifts from dispensing information to designing and managing the overall instructional process” (p. 10).
Table: Faculty Preparation for Team-Based Learning
Although students had been introduced to TBL in a previous course, during the initial class session the instructors reviewed the concepts of TBL, the expectations of the students, and the integration of TBL in this specific maternal–newborn nursing course. To meet the goal of forming heterogenous teams, students were asked specific questions, such as “Are you a parent?” “Have you observed a live vaginal birth?” and “Have you viewed a recorded delivery on television?” As soon as a student answered yes to an item, he or she took his or her place in a line formed around the perimeter of the classroom. Students were then assigned a number based on their location in line and were placed in teams of five participants. According to the recommendations by Michaelsen and Sweet (2008b) regarding team formation, five to seven members should compose each heterogeneous team.
During this initial class session, a rubric for peer evaluation was distributed, which listed preparation, contribution, and respect for others as criteria for peer evaluations to be completed at the conclusion of the semester. Each newly formed team identified two additional items to be included. Attitude, attendance, and punctuality were most often selected by the groups as additional criteria. Peer evaluation allowed students to rate their team members on five identified characteristics of behavior displayed throughout the course during the semester. Sibley and Parmelee (2008) found that students who choose criteria for the peer evaluation took the process and the associated grade more seriously.
An ideal classroom environment for active learning in small groups would incorporate flexible furnishings with round tables and moveable chairs. Rearranging the physical environment was needed each class day to facilitate team interaction. On nonexamination days, students first completed the 20-item IRAT, while seated six per table in rows on each side of a center aisle. Chairs and tables were then rearranged to allow teams to complete the identical GRAT.
For each class period, four to six learning activities were created to enhance student knowledge and understanding of the assigned content. The variety of learning activities prepared by faculty included crossword puzzles, case studies, analysis of food diaries and body mass index calculations, and the development of cultural and age-appropriate childbirth educational content, as well as multiple choice–style items relating to content. In addition, simulated activities provided realistic experiences and promoted team discussion within the classroom. An example included using newborn manikins labeled with assessment data. The teams assigned an Apgar score and discussed related nursing care and interventions. Students remained in their assigned teams to complete learning activities and were allowed approximately 15 to 20 minutes to complete the assignment. Following independent team work, an open discussion of ideas and responses occurred with the entire class. Instructor feedback and clarification were also provided immediately following the completion of activities. Learning activities were not assigned any graded points.
Assessment of Student Learning
The strategies for measuring student learning were also modified due to the implementation of TBL, with assessments occurring more frequently. Readiness Assurance Tests (IRATs and GRATs) were administered throughout the semester. Each student took the IRAT and submitted an answer sheet, which was computer scanned. Students then convened in their teams to take the GRAT and used the scratch-off Immediate Feedback-Assessment Technique forms, with items precoded to reveal the correct answers. These forms are available at http://www.epsteineducation.com/home/. Scores on each GRAT were weighted double the value of scores of the corresponding IRAT to reflect the importance of intrateam collaboration in answering the items. At the conclusion of each IRAT and GRAT session, students had the opportunity to submit an appeal of a test item if he or she believed it was worded incorrectly or if he or she found another answer to be correct. The appeal required evidence from the assigned readings to support his or her argument.
Throughout the semester, seven IRAT and GRAT quizzes were administered, and the scores of six IRAT and GRAT quizzes were included in the final course grade. In addition to the IRAT and GRAT quizzes, four multiple choice unit examinations consisting of 45 items, along with a cumulative final examination of 60 items, were administered to the students. The faculty made the deliberate decision not to administer IRATs and GRATs on the same class day as a unit examination. The frequency of unit examinations remained unchanged with the transition to TBL. The addition of more NCLEX®-style items at a higher level of difficulty were beneficial to the students in the TBL course. In addition, to emphasize the accountability of both the individual and the team, which is one of the basic principles of TBL, each IRAT item was valued at 0.25, and each GRAT item was valued at 0.5 (Michaelsen & Sweet, 2008b).
During the last class session of the semester, students were required to complete a peer evaluation of fellow team members based on his or her contributions to the weekly activities. The sum of scores received by each student based on their team’s evaluation rating was converted to a rating ranging from zero to 5 points, which was then added to the theory grade. Students’ anonymity was provided to assist with honesty in completing the form. Students did not view the completed written peer feedback from the evaluation forms but rather viewed only the numerical grade provided.
Many lessons were learned throughout the semester of implementation. Developing learning activities requires a tremendous amount of time and effort. Some of the new activities facilitated student learning, whereas others were unsuccessful and were not used in subsequent semesters. For example, a learning activity that focused on genetics was too detailed and was therefore discarded, whereas the Apgar learning activity described previously proved to be beneficial and will continue to be used. As the course shifted from the traditional lecture accompanied by PowerPoint slides to TBL, the control of learning also shifted from the instructor to the students. Instructors had to let go of the perception that if content was not discussed in class, students would not learn it.
In addition, the instructors anticipated a range of reactions from students to the change in teaching strategies and the use of classroom time. Some students enjoyed TBL, citing that the preclass reading assignments assisted them in preparing for class. One student stated, “I honestly do like that we have to read for the class.” Another insightful student recognized the benefit of teamwork as “learning how to work with others, using others’ feedback to increase your own intelligence.” However, although some students enjoyed TBL, others voiced concern and frustration with the lack of lectures and their own new responsibility in the learning process. One student stated, “The teachers are paid to TEACH, not to watch us learn. I pay for the teachers to teach me.” This feedback is consistent with the literature (Clark et al., 2008; Mennenga & Smyer, 2010) and is expected because students have become accustomed to the traditional lecture format conducted in a passive learning environment (Janssen et al., 2008; Young, 2009). Until students are acclimated to being active, engaged learners in their education, instructors using TBL may face some resistance. A discussion with administration about the concepts and evidence-based benefits of TBL is strongly encouraged prior to its implementation. Ideally, administrators should encourage instructors to continue this evidence-based teaching strategy, despite possible lower ratings on instructor and course evaluations.
Overall, the experience of converting a maternal–newborn nursing course from the traditional lecture format to TBL was a positive, yet challenging, learning experience. The increased frequency of assessment exposed students to a greater number of NCLEX-style items but required more instructor time to develop additional test bank items. Furthermore, instructors were encouraged by the dialogue of students working in teams, although at times the classroom became noisy and somewhat chaotic. Students appeared more engaged in the classroom setting; however, they often failed to recognize the benefits of TBL. Future research may address students’ attitude to change in pedagogy and assessment of student learning.
- Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
- Clark, M., Nguyen, H., Bray, C. & Levine, R. (2008). Team-based learning in an undergraduate nursing course. Journal of Nursing Education, 47, 111–117. doi:10.3928/01484834-20080301-02 [CrossRef]
- Dana, S. (2007). Implementing team-based learning in an introduction to law course. Journal of Legal Studies Education, 24(1), 59–108. doi:10.1111/j.1744-1722.2007.00034.x [CrossRef]
- Di Leonardi, B. (2007). Tips for facilitating learning: The lecture deserves some respect. The Journal of Continuing Education in Nursing, 38, 154–161.
- Fink, L. & Parmelee, D. (2008). Preface. In Michaelsen, L., Parmelee, D., McMahon, K. & Levine, R. (Eds.), Team-based learning for health professions education: A guide to using small groups for improving learning (pp. xi–xv). Sterling, VA: Stylus.
- Janssen, H., Skeen, N., Schutt, R. & McMahon, K. (2008). An educational rationale for the use of team-based learning. In Michaelsen, L., Parmelee, D., McMahon, K. & Levine, R. (Eds.), Team-based learning for health professions education: A guide to using small groups for improving learning (pp. 75–83). Sterling, VA: Stylus.
- Jones, S. (2007). Reflections on the lecture: Outmoded medium or instrument of inspiration?Journal of Further and Higher Education, 31, 397–406. doi:10.1080/03098770701656816 [CrossRef]
- McInerney, M. & Fink, L. (2003). Team-based learning enhances long-term retention and critical thinking in an undergraduate microbial physiology course. Microbial Education, 4(1), 3–12.
- Mennenga, H. & Smyer, T. (2010). A model for easily incorporating team-based learning into nursing education. International Journal of Nursing Education Scholarship, 7, Article 4. doi:10.2202/1548-923X.1924 [CrossRef]
- Michaelsen, L. & Sweet, M. (2008a). The essential elements of team based learning. In Michaelsen, L., Sweet, M. & Parmelee, D.X. (Eds.), Team-based learning: Small-group learning’s next big step (pp. 7–27). Danvers, MA: Wiley.
- Michaelsen, L. & Sweet, M. (2008b). Fundamental principles and practices of team-based learning. In Michaelsen, L., Parmelee, D., McMahon, K. & Levine, R. (Eds.), Team-based learning for health professions education: A guide to using small groups for improving learning (pp. 9–31). Sterling, VA: Stylus.
- Opdecam, E. & Everaert, P. (2012). Improving student satisfaction in a first-year undergraduate accounting course by team learning. Issues in Accounting Education, 27(1), 53–82. doi:10.2308/iace-10217 [CrossRef]
- Parmelee, D. (2008). Team-based learning in health professions education: Why is it a good fit? In Michaelsen, L., Parmelee, D., McMahon, K. & Levine, R. (Eds.), Team-based learning for health professions education: A guide to using small groups for improving learning (pp. 3–8). Sterling, VA: Stylus.
- Sibley, J. & Parmelee, D.X. (2008). Knowledge is no longer enough: Enhancing professional education with team-based learning. In Michaelsen, L., Sweet, M. & Parmelee, D.X. (Eds.), Team-based learning: Small-group learning’s next big step (pp. 41–53). Danvers, MA: Wiley.
- Young, J. (2009, July24). When computers leave classrooms, so does boredom. The Chronicle of Higher Education, 55(42), A1–A13.
Faculty Preparation for Team-Based Learning
Prepare reading assignments pertinent to learning outcomes and activities.
Develop learning activities that allow students to apply material.
Purchase IRAT and GRAT forms.
Develop IRATs and GRATs for each unit of study.
Prepare a sample IRAT and GRAT and learning activity covering the syllabus as a method of orientating students to TBL.
Provide students with a short summary of the TBL approach (e.g., history, current research of benefits, student expectations, faculty expectations).
Allow the students time to develop team names and peer evaluation indicators.
Complete the practice IRAT and GRAT and learning activity based on the syllabus.
Allow students the opportunity to ask questions.
Ensure reading assignments are posted.
Empty completed learning activities from team folders.
Review learning activities and make changes as needed.
Correct IRAT and GRAT and postscores.
Develop unit examinations.