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Nurses’ perceptions of the impact of Team-Based Learning participation on learning style, team behaviours and clinical performance: An exploration of written reflections
Accepted Manuscript Nurses’ perceptions of the impact of team-based learning participation on learning style, team behaviours and clinical performance: An exploration of written reflections Elizabeth Oldland, Judy Currey, Julie Considine, Josh Allen PII:
S1471-5953(17)30198-1
DOI:
10.1016/j.nepr.2017.03.008
Reference:
YNEPR 2205
To appear in:
Nurse Education in Practice
Received Date: 26 January 2016 Revised Date:
1 November 2016
Accepted Date: 28 March 2017
Please cite this article as: Oldland, E., Currey, J., Considine, J., Allen, J., Nurses’ perceptions of the impact of team-based learning participation on learning style, team behaviours and clinical performance: An exploration of written reflections, Nurse Education in Practice (2017), doi: 10.1016/ j.nepr.2017.03.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT NURSES’ PERCEPTIONS OF THE IMPACT OF TEAM-BASED LEARNING PARTICIPATION ON LEARNING STYLE, TEAM BEHAVIOURS AND CLINICAL PERFORMANCE: AN EXPLORATION OF WRITTEN REFLECTIONS
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Author names and affiliations Elizabeth Oldland1 Professor Judy Currey1 Professor Julie Considine1 Josh Allen1
Deakin University, Geelong, School of Nursing and Midwifery, 221 Burwood Hwy,
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1
Burwood, Victoria, Australia, 3125
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Email: [email protected]; [email protected]; [email protected]; [email protected]
Corresponding Author: Elizabeth Oldland, Deakin University, Geelong, School of Nursing and Midwifery, 221 Burwood Hwy, Burwood, 3125, Victoria, Australia.
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Word Count: 5450
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[email protected]. +61 3 92446608
Funding acknowledgement: A Deakin University School of Nursing and Midwifery small
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research grant ($4000) supported employment of a research assistant.
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Abstract Team-Based Learning (TBL) is a teaching strategy designed to promote problem solving,
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critical thinking and effective teamwork and communication skills; attributes essential for safe healthcare. The aim was to explore postgraduate student perceptions of the role of TBL in shaping learning style, team skills, and professional and clinical behaviours.
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An exploratory descriptive approach was selected. Critical care students were invited to provide consent for the use for research purposes of written reflections submitted for course
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work requirements. Reflections of whether and how TBL influenced their learning style, teamwork skills and professional behaviours during classroom learning and clinical practice were analysed for content and thematic analysis.
Of 174 students, 159 participated. Analysis revealed three themes: Deep Learning, the adaptations students made to their learning that resulted in mastery of specialist knowledge;
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Confidence, in knowledge, problem solving and rationales for practice decisions; and Professional and Clinical Behaviours, including positive changes in their interactions with colleagues and patients described as patient advocacy, multidisciplinary communication
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skills and peer mentorship.
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TBL facilitated a virtuous cycle of feedback encouraging deep learning that increased confidence. Increased confidence improved deep learning that, in turn, led to the development of professional and clinical behaviours characteristic of high quality practice.
ACCEPTED MANUSCRIPT Keywords: Critical care nursing; Learning style; Nursing education; Team-Based Learning Highlights Team-Based Learning develops active learning styles and positive professional behaviours
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Develops deep learning, increasing confidence
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Expressed as improved patient advocacy and multidisciplinary communication
Supports development of knowledge, skills and behaviours for quality
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•
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skills
healthcare
INTRODUCTION
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Nurses, as the largest healthcare workforce, play a pivotal role in the provision and coordination of care, prevention of adverse events, and optimisation of health service productivity and patient outcomes (Aiken et al., 2014; Buchan and Aiken, 2008).
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Over the last two decades, a core set of health professional competencies designed to encapsulate knowledge skill and behaviours in a safety and quality framework has
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emerged (Australian Council for Safety and Quality in Health Care, 2005; Frank et al., 2008; Institute for Healthcare Improvement, 1998; Institute of Medicine, 2003; World Health Organization Core Team, 2011). These competencies are considered as important to curricula as they are to clinical practice (Currey et al., 2015c). In tertiary education institutions across Australia, Europe and the US, incorporating teaching and assessment practices that develop and assess generic attributes are considered essential (Barrie et al., 2012; Collins and Hewer, 2014; National Institute for Learning Outcomes Assessment, 2012). Such higher degrees ensure that 1
ACCEPTED MANUSCRIPT generic skills highly valued by employers are taught along with discipline specific content. Indeed, generic attributes common to most universities include written and oral communication, critical and analytical thinking, problem solving, information literacy, learning and working independently and collaboratively, and ethical and
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inclusive engagement with communities, cultures and nations (Oliver, 2011).
Nursing education must be designed to produce graduates who are equipped with generic skills, and discipline specific knowledge and skills that meet the needs of
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their patients. There is mounting evidence that well developed communication and
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reflection skills along with effective team behaviours are central to the delivery of safe and high quality care, reducing the risk of error in health care, and improve health outcomes and patient experiences (World Health Organization [WHO], 2011). Various approaches have been implemented in health education to support acquisition of these skills, including problem based learning (Barrows 1996), inquiry
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based learning (Feletti, 1993), self-directed learning (Levett-Jones, 2005), and simulation (Norman, 2012). Each has its own strengths and limitations (Levett-Jones,
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2005; Wozniak et al., 2005). Cognizant of the imperative to better prepare registered nurses for the demands of critical care specialty practice areas, in 2009 the faculty of
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an Australian University introduced Team-Based Learning (TBL) (Michaelsen et al., 2008) into the curriculum of a postgraduate specialist critical care nursing programme. This educational strategy was selected to accelerate students’ attainment of learning outcomes requiring higher order critical thinking and problem solving skills, and to enhance graduate employability and patient safety through the development of teamwork, reflection and communication skills.
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ACCEPTED MANUSCRIPT BACKGROUND Team-Based Learning uses instructional principles that maximise student preparation and participation, which in turn foster high levels of team performance.
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Students are held accountable for their own learning before and during class, spend class time applying newly acquired knowledge to real clinical problems, and develop team and communication skills through the creation of essentially self-managed high performing teams (Kelly et al., 2005; Michaelsen et al., 2008; Michaelsen and Sweet,
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2011).
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All TBL material is designed utilising the process of backwards design (Biggs and Tang, 2011), commencing with writing intended learning outcomes for the module, providing resources that will assist the students to meet the outcomes, and developing assessment questions that allow students to demonstrate mastery of the
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learning outcomes. The strategy consists of a repeating sequence of four phases (summarised in Table 1). In Phase 1, students undertake pre-learning prior to coming to class using instructor provided resources or direction informed by clear
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intended learning outcomes. In Phase 2, the readiness assurance process, students undergo an individual multiple choice test of the topic’s core concepts. This is
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conducted at the beginning of the class and scores are submitted for grading. Before the answers are discussed, students take the same test as a member of a preformed and ongoing team of 5-7 members. Teams are allocated by the instructor to ensure team diversity based on specialty stream and place of employment. Team members come to agreement on each answer, requiring articulation and defence of their a position, and teams receive instant feedback on their chosen answer through the use of “scratch off” cards to reveal the correct answers. The Phase 2 scores are submitted and graded. This phase provides an incentive to prepare and contribute to 3
ACCEPTED MANUSCRIPT the team. In Phase 3, the team apply knowledge acquired and demonstrated through Phases 1 and 2 to a number of authentic problems (applications). Teams must make a specific choice and simultaneously report their team’s answer at which point the teacher facilitates an inter-team discussion. This phase promotes a vigorous
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discussion with students defending or refining their position in response to inter-team debate. This process, plus periodic formative and summative peer evaluation of each team member’s contribution and team behaviours (Phase 4), promotes depth of
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knowledge, problem solving skills, and positive personal and team behaviours
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(Haidet et al., 2012).
Table 1 Phases of Team-Based Learning PHASE 2
Pre-class learning
Readiness Assurance Process
• Individual test answers submitted for grading • Teams take test and reach consensus by discussion • Team answers submitted and graded • Instructor feedback
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• Study materials provided, including instructorset learning objectives
Individual and team multichoice test
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Independent student learning
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PHASE 1
PHASE 3
PHASE 4
Application of course concepts
Peer evaluation
In class team assignment
Formative and summative
• Cooperative problem solving • Instructorfacilitated class discussion between teams
Adapted from Currey et al. 2015a and Michaelsen and Sweet, 2011)
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ACCEPTED MANUSCRIPT There is a volume of TBL research that demonstrates improved student engagement and attitudes to teamwork, and a preference for this teaching strategy over didactic teaching (Clark et al., 2008; Currey et al., 2015a; Currey et al., 2015b; Haber and Boomershine, 2015; Hazel et al., 2013; Imazeki, 2015; Levine et al., 2004; Macke et
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al., 2015; Morris, 2016; Park et al., 2015; Roh et al., 2015; Tucker and Brewster, 2015). There is some evidence that students undertaking TBL have improved
academic performance (Harmon and Hills, 2015; Koles et al., 2010). However the
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evidence of sustained or higher learning outcomes assessed in test format is not conclusive as illustrated in two systematic reviews (Fatmi et al., 2013; Sisk, 2011).
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Most TBL research involves undergraduate students in the academic setting and most participants studied are not yet qualified or employed in their discipline. There are inherent and significant difficulties with trying to measure the real learning and performance outcomes of TBL in any graduate. Results of a recent qualitative study
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conducted by the authors demonstrated that industry educators believed graduates of courses using TBL displayed a range of graduate attributes not recognised in graduates of non-TBL courses (Oldland et al., 2012). However, student perceptions
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of how TBL shapes the development of graduate attributes such as communication,
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teamwork and reflection skills, and the impact of this on professional behaviour is unknown. Postgraduate nursing students are employed concurrently in industry, and thus provide good measure of the impact of TBL on graduate attributes in practice. RESEARCH AIM
The aim of this study was to explore student perceptions of the role of Team-Based Learning in shaping their learning style, team skills, and professional clinical behaviours.
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ACCEPTED MANUSCRIPT METHODS Study Design An exploratory, descriptive research design was used to address the study aim.
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Setting and Sample The study was undertaken during 2012 and 2013 in the specialty practice courses (Intensive Care, Cardiac Care, Emergency Care, and Critical Care) nested within the
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Master of Nursing Practice in an Australian University. To gain a specialist
qualification, critical care qualifications are completed over 1 to 2 years, with the
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University delivering theoretical content while nurses are concurrently employed in specialty units of hospitals. Students are supervised by hospital employed clinical nurse educators who provide clinical support and perform clinical assessments, thus ensuring the application of theory to practice in complex, highly demanding workplaces. Registered nurses must undertake four specialist units within an
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academic year. These units are embedded within a broader 12 unit Master’s degree. Each TBL session was conducted on a study day, on alternate weeks, for two
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sequential 12 week semesters. There were a total of 12 sessions each lasting 2 hours. Non-TBL sessions were delivered using didactic teaching methods and
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tutorials at other times on each study day. Each TBL session addressed core, complex topics within the curriculum such as advanced haemodynamics, temporary pacing, and shock. Students stayed in the same team for a semester then formed a new team for the second semester. Each session was facilitated by two of four trained TBL facilitators depending on content expertise. We incorporated all seven core elements of TBL: team formation, readiness assurance (RA), immediate feedback, sequencing of in-class problem solving, the four S’s (significant and same
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ACCEPTED MANUSCRIPT problem, specific choice, and simultaneous reporting), incentive structure, and peer review (Haidet et al., 2012). In accordance with published guidelines for the reporting of TBL research (Haidet et al., 2012), an overview of the inclusion and operationalisation of the seven core elements of TBL is provided in an online
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Supplementary File.
Reflective practice is a key course, university and discipline specific graduate
learning outcome and an essential professional behaviour for safe and high quality
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patient care (Nursing and Midwifery Board of Australia [NMBA], 2016). For this
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reason, the development and assessment of this skill is purposefully embedded throughout our course and intentionally assessed, including through TBL. As part of their TBL course work, all students are asked to submit a short written reflection. The question prompt for reflection is “What (if anything) have you learned about yourself as a learner, team member and clinical nurse as a result of participating in Team-
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Based Learning?” The item is due on the last day of the course and is submitted electronically to the Course Leader via email. This piece contributes 2.5% to the
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course grade. The assessment criteria for allocation of this 2.5% are that the reflection is approximately 150-300 words and demonstrates evidence of reflection. It
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is made very clear, both verbally and in written instruction that students are expected to be honest, and may well reflect that TBL has no influence at all. All students participating in TBL in two consecutive years of specialist graduate certificate courses (Intensive care, Cardiac care, Emergency care, Critical care), embedded within the Master of Nursing Practice (N = 174 students) were eligible to participate in the study (census sampling).
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ACCEPTED MANUSCRIPT Data Collection and Procedure In the week after the assessment requirement was explained to students, a member of the research team (JA) who had no teaching or assessment responsibilities in the course invited all students to participate by giving consent for the use of their
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submitted written reflection for research purposes. Students were informed that
participation was voluntary and their choice to participate or not could in no way influence their marks or relationship with any member of the teaching staff who
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would have no knowledge of a student’s participation status. Information about the
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study was also provided in a written plain language statement. Consent to participate was by return of a signed consent form and non-identifiable demographics information to JA in the classroom or via post. The Course Leader forwarded by email all students’ reflections to JA who then ‘cut and paste’ into an excel spreadsheet the deidentified reflections of the students who had provided consent to
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participate in the research project. Each participant’s reflection was given a code number. After course completion and release of final results, JA provided the deidentified data of participating students to all members of the research team. This
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process was engaged to protect participants’ anonymity and addressed the potential
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power imbalance by removing the staff members who teach and assess in the course from the stages of communicating information about the research and data collection phases of the project. There were no exclusion criteria. Ethics approval for the study was granted by the University Human and Research Ethics Committee. Participants’ consent forms were stored in a locked filing cabinet in a locked University office.
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ACCEPTED MANUSCRIPT Data Analysis First pass data analysis was performed on deidentified data by a research assistant (JA) who was not a member of the teaching team. Participant reflections were analysed using the established complementary techniques of thematic and content
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analysis (Elo and Kyngäs, 2008; Lincoln and Guba, 1985). A qualitative data
analysis software package, NVivo (2012) was used to store and manage data. Content analysis techniques combined deductive and inductive techniques to
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identify themes, and resulted in final themes that are both descriptive and
explanatory. Initial results were analysed for overlap, redundancy, emergence of
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any new themes, and relationships between themes (Lincoln and Guba, 1985) by three members of the research team (EO, JCu and JA). Peer collaborations, peer debriefing, rich thick descriptions of data and open transparency about research aims enhanced the rigor of the research (Lincoln and Guba, 1985; Mays and Pope,
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2000; Schneider et al., 2007). As the reflections were deidentified, member checking was not possible.
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FINDINGS
Of the sample, 172 consented to participate (99% response rate); however, only 159
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subsequently submitted a written reflection (91% response rate). Demographic data are presented in Table 2. The majority of the participants were female (90%) aged 26-30 (38%), with between 3 and 5 years’ experience as a registered nurse (59%). Of those years as a registered nurse, 2 to 3 years were in a specialty practice setting (51%).
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ACCEPTED MANUSCRIPT Table 2. Participant demographics
18 154
10 90
48 65 30 29
28 38 17 17
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9 102 35 23
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%
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Gender • male • female Age group (years) • 22-25 • 26-30 • 31-35 • 36+ Years as Registered Nurse (missing n=1) • 1-2 • 3-5 • 6-10 • 11+ Years in Speciality Practice (missing n=1) • 0-6 • 2-3 • 4-5 • 6+
n
26 51 11 12
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46 87 18 20
6 59 20 13
Thematic analysis of the data revealed three themes: 1. Deep Learning, 2.
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Confidence, and 3. Professional and Clinical Behaviours. The three themes are
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closely linked and interrelated (see Figure 1).
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Figure 1. Thematic analysis of participants’ reflections. 1. Deep Learning
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In Deep Learning, students reflected on the deep learning they had experienced as a result of their TBL experiences. This deep learning was attributed in the reflections to two distinct constructs: content learning and practicing for practice.
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Content learning
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The first construct was content learning, in which students reflected on the adaptations they had made to their own learning style and on their motivation to learn in the context of TBL. Many students reflected on what they saw as a need to adopt a new learning style for TBL material, including adjusting study habits. I became a more active learner after about 3 TBL sessions (R150);
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ACCEPTED MANUSCRIPT TBL has allowed me to discover that in order to learn the content I need to externalise it (R123). The students described changes to the way they studied course material when
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alone, taking a more active approach to their study (for example, explaining a concept out loud, mind mapping, and the adoption of more group based study). For many students, TBL took over as the preferred method of study.
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My learning style used to be composed of individual study with reading and learning on my own. However throughout this year of study I have found it
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increasingly hard to learn this way. I now find it challenging to learn on my own, and feel I require the group environment and ‘team’ to learn new information and to apply myself to study. Group study sessions benefit me the most, with talking out loud now my favoured way to actually feel like I am
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taking in the information being taught (R28);
TBL changed my learning style. I only studied hard before exams during my
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undergraduate study. Now, I study before every TBL session. I don't feel too
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much stress at the end of semester because most of the content has been tested during TBL. TBL shows me the study direction (R50).
For those who self-identified strongly as preferring to study alone, their original preferences remained, although they were able to adapt to the new learning style. Although, this type of learning is perhaps not suited to myself, I did learn from others' discussions and the case studies were particularly helpful to relate
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ACCEPTED MANUSCRIPT new knowledge to clinical areas. Overall, my learning style has remained the same (R4). It may be that those students who identified a preference for studying alone were
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those who had already developed sound study techniques and were accustomed to high grades.
Being motivated to learn course content was a strong finding in the reflections which
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was expressed as two distinct motivations for learning: assessment and not wanting to let the team down or to establish their credentials. Many students identified TBL
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assessments (20% of summative grades) as the main driver of learning, while others believed that being able to contribute to the team was their primary motivator. TBL weekly tests compelled me to learn the topics thoroughly (R4);
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TBL encourages a lot of independent studying, everyone would like to be a competent practitioner/student amongst our colleagues/teams
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(R52);
My desire to be an effective member of the team and not be a weak link, has added impetus for studying prior to the TBL session (R57).
A few identified ‘carrot and stick’ motivations to learning. Students wanted to ensure they had learned the content to pass/receive marks or to impress the team/establish their credentials (carrots); and didn’t want to let their team down (stick). I felt pressure to be prepared, in order to assist myself and my team in succeeding. The pressure became determination and facilitated a 13
ACCEPTED MANUSCRIPT positive learning experience. Independent learning gave me great satisfaction and a sense of pride. I could gauge my performance and gain positive and negative feedback on my level of knowledge (on)
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clinical and theoretical components (R31);
I realised from the first TBL session that I needed to come prepared to
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be able to participate and help the group get good marks along with
increasing my knowledge...It helped me study each week, as I knew I
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had to contribute to help my team (R7).
It appears that the short term incentive to learn had much more bearing on student motivation than medium or long term goals. Many noted that TBL was an effective preparation for final exams; however, students were also able to link the learning that
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took place in TBL with their clinical practice. This was illustrated in the second construct of the deep learning theme. Practicing for practice
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The second construct identified within the theme of deep learning was ‘practising for
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practice’. This was expressed by students as the learning and development of new skills through testing and justifying knowledge, small and large group communication, and teamwork skills. Students tested and rationalised their new knowledge through the process of defending and justifying their answers. This process was beneficial to learning and clarifying difficult concepts. Students valued the supportive environment where they could offer an explanation for an answer or treatment decision based on physiology or evidence. Students also valued when
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ACCEPTED MANUSCRIPT their team members sought clarification, challenged an answer or provided another viewpoint. Thus, peer feedback was essential to this theme. Knowing and understanding clinical information helped me to be more
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confident talking to doctors and others in the unit, be confident about my answers to their questions, or have an idea or where to find the answers to them if I didn’t know. I’m much more confident about being able to look at the patient as a whole person, rather than just looking at parts of them;
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connecting data to make a whole picture instead of just looking at the
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information separately (R29);
While finding the questions very challenging, being able to provide a rationale for "why wasn't answer 'a' correct?" that seemed to really cement to me that
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even if I was not entirely sure of the answer I could still provide a rationale for why I may not have chosen a particular answer (R41);
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I found TBL helpful to improve my knowledge. Having to talk through the
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answer and explain my reasoning to others meant that I found I had good knowledge on the topic (R13).
By testing and justifying knowledge in the TBL environment, they learned course content; that is, discipline specific knowledge more deeply and ‘practiced for practice’. Rehearsing verbal rationale clarified and reinforced understanding. Participants made clear links between this ‘practicing’ and the requirement for this level of understanding and articulation in the clinical environment.
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ACCEPTED MANUSCRIPT Unless I can explain my ideas well to my teammates, I have never really understood the basic concepts of that topic well enough, because my ideas
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can be easily challenged by the others (R47);
TBL helped me learn things in a manner I clearly understand. I am able to explain in a clear and succinct manner to my fellow team members, the
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educators in my clinical area and all other members of the multidisciplinary team at work. My confidence in what I say has increased markedly and I the
has been great (R41).
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directors of my unit ask me more questions during the medical round which
Many students commented they had learned more about themselves through peer evaluation. Peer evaluation in TBL is designed to provide feedback, develop
unhelpful behaviours.
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reflective and peer evaluation skills, reinforce positive behaviours, and modify
TBL and peer evaluation has taught me that I can be quite overpowering and
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forthright in defending my views and that sometimes I need to step back and
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invite the opinions of other colleagues (R142). Several students were disarmingly honest about peer feedback that highlighted poor communication; for example, speaking over others, interrupting and discouraging other views. For these students, structured, honest, timely and respectful peer feedback was transformative in improving their communication skills.
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ACCEPTED MANUSCRIPT 2. Confidence In the second theme students reflected on the increased confidence acquired through improved knowledge and problem solving skills, and articulation of rationales for practice decisions. They reported increased confidence in their own clinical
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knowledge and communication skills in class and clinical environments.
What gives me confidence in speaking up is an in-depth knowledge on the subject, and as the year has gone on and my own knowledge base has
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increased, it has become much easier to be able to stand up and say my
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piece - I think that in part is due to actually understanding the topics (R53);
It helped me realise that I should have more confidence and knowledge to be able to speak up more confidently when I know I am speaking the right matter
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and should be able to convince the other person with a valid rationale (R39).
Students often made the link between the deep learning of content and having
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confidence in their knowledge, speaking in TBL and speaking with other clinicians in
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their workplace such as the ward round.
My level of confidence grew and public speaking became part of the learning experience, and has assisted me in my workplace to approach senior medical staff and maintain my role as a patient advocate in any situation (R170);
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ACCEPTED MANUSCRIPT Having a wider knowledge base from participating in TBL, I now have more confidence to question patient management plans and be a more active member of a multidisciplinary team (R6).
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Students’ fear of being 'wrong' was allayed, giving students the confidence to speak up, both in class and in a multi-disciplinary clinical context. Students also described occasions when they did not have the confidence to speak up, despite feeling that
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they had the correct answer. This was sometimes attributed to confidence in
speaking up, fear of being wrong, or on other group members not creating the
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opportunity.
My main problem was my lack of confidence to say what I think as I was too afraid that I might be wrong. It annoyed me even more when I was right that I didn't try hard enough to make my points heard…but then the more TBL we
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did in class the more confident I felt and a little better I got at explaining things to others. As the comfort built up in the group I was more able to say what I
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thought (R60);
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Initially it was bit overwhelming for me because I found it little hard to express myself in front of huge class as I am not a very good speaker generally. But as the course went on, I found myself speaking. And that helped me develop confidence while having discussions with the medical team (R1).
Confidence was an outcome of TBL that reinforced deep learning (theme 1) which in turn translated into professional and clinical behaviours (theme 3).
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ACCEPTED MANUSCRIPT 3. Professional and Clinical Behaviours The third theme identified was Professional and Clinical Behaviours. Professional behaviours included leadership, role-modelling and teamwork skills; the development of which many attributed to TBL. A number of students reflected they had learnt or
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discovered innate leadership skills during TBL. Students reflected that they were beginning to act as role-models in their workplace. Clinical skills gained from TBL included patient advocacy, contribution to team decisions, and quality nursing care.
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I have found my voice in nursing. I take a more active part in the decision
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making process of patient care. I ask questions if I’m not sure about why certain decisions are made, I make suggestions and colleagues listen (R116);
TBL certainly developed my listening and negotiating skills and I can see this
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being beneficial to resolve conflict within the department. TBL has also made me aware of the role of teamwork within critical care nursing, that collaboration is essential to provide excellent patient care and develop lasting
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profession relationships with colleagues (R11);
I learnt to trust myself, to trust what I knew and not to be scared to speak up if I didn’t necessarily agree. It has transferred over to my clinical area where I no longer just take orders from doctors, but rather take an active part in the decision making process of patient care. I ask questions if I’m not sure about why certain decisions are made, I make suggestions and colleagues listen. I have found my voice in nursing, and I truly believe it can only get better with time (R25).
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ACCEPTED MANUSCRIPT A number of students reflected that they had learnt or discovered leadership skills during TBL. A number of students also reflected that they were beginning to act as role-models at work. I have learnt valuable lessons about my role in a group and found to my
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surprise that I no longer sit back but am capable of being a leader within a group. This is a result of the self confidence that acquiring in-depth knowledge
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brings and I am a much better clinical nurse as a result (R11);
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I have changed and grown as an individual and my nurse colleagues now seek my opinion on best practice issues in ward, which I find a privilege that I’m now a valued Team member, and my opinion matters (R12);
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I have discovered that I have some natural leadership abilities and I think these have developed during TBL (R56).
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For others, it was a reflection on their own position in the workplace, the contribution
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they made to improvements in evidence-based practice, and their acceptance of their professional responsibility to assist other staff to provide safe and high quality care.
TBL has changed me to challenge poor practice and initiate evidence-based practice in clinical area (R37);
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ACCEPTED MANUSCRIPT TBL regularly focused on evidence-based practice which fuelled my enthusiasm in transferring evidence-based practice to the bedside and
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assisted my development to become a better advocate for my patients (R55);
TBL also helped the patient clinical presentation was not cut and dry. I am able to teach evidence to other nurses and have the confidence to do so (R2).
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Finally, some participants directly acknowledged they had become reflective and developed insights into their own strengths and weaknesses. Although a subjective
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review of the participants’ responses demonstrates varying levels of reflective abilities, this is consistent with the any skill development of learners. Most students reflected upon a change in learning style facilitated by TBL, while others felt that their learning style had remained unchanged, sometimes in spite of TBL.
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I don’t feel that my learning style has changed much this year. I have always really enjoyed solitary study; however, I do realise that working as a nurse and problem solving sometimes demands group work and feel I appreciate group
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work more (R110);
I don’t believe that TBL has changed my communication style, which is very much about listening and respecting the opinions of others, as well as having an opinion myself to put forward. It has however helped my confidence level in communicating effectively to small and large groups (R158).
Some students referred to TBL only as a tool for learning whereas others were able to see the implications this learning method had on their clinical and professional
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ACCEPTED MANUSCRIPT practice. No student expressed an increase in their confidence to be a reflective practitioner.
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DISCUSSION This novel study sought student perceptions of how, if at all, TBL influenced their learning style, teamwork skills, and professional behaviours. This unique perspective was possible because students were studying at postgraduate level and in
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concurrent professional practice.
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Findings showed students attributed learning via TBL to deep learning of cognate knowledge, raised confidence as a learner and professional practitioner, and developing or improving their professional and clinical behaviours. The acquisition of critical thinking, problem solving and teamwork behaviours have been identified as
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critical to reducing patient harm improving the quality of care provided (World Health Organization Core Team, 2011). There is emerging evidence that the structure and process of TBL supports development of these attributes in undergraduate nursing
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programmes, (Clark et al., 2008; Feingold et al., 2008; Harmon and Hills, 2015; Mennenga, 2013; Park et al., 2015; Roh et al., 2015) and more recently in
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postgraduate nursing (Currey et al., 2015a; Currey et al., 2015b). Findings of this study provide further evidence from the learners’ perspectives about the value of TBL for developing and consolidating these skills. Our findings about students’ attribution to TBL for deep learning of key discipline-specific concepts and enhanced teamwork confirms that of Morris (2016) in undergraduate nursing courses. Feelings of, or growth in, student confidence have not been attributed to TBL in previous research. It is possible that confidence was a strong finding in this study
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ACCEPTED MANUSCRIPT due to students’ context of concurrent professional practice. Participants linked confidence to improved knowledge and problem solving skills, and clearly identified a virtuous cycle of confidence, knowledge, and public speaking. It is argued the provision of a safe place for students to develop these skills in a TBL classroom
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enables this cycle of professional development that students articulated so well. Participants related their increased confidence with improved patient advocacy,
interprofessional collaboration, and professional leadership behaviours. Improved
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professional team behaviours have been reported in previous TBL literature
(Gallegos and Peeters, 2011; Park et al., 2015); however, further studies are
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required to confirm findings of advocacy and leadership behaviours considering the importance of these attributes for nursing practice (Australian College of Critical Care Nurses, 2006; College of Emergency Nursing Australasia, 2013; NMBA, 2016; WHO, 2011) and safety in healthcare.
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This study has certain limitations. We do not claim a cause and effect relationship between TBL and self-reported benefits, nor conclude that students’ self-reported
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skills are demonstrated in practice. Although there were other ways in which student learnt in this course, predominantly experiential in practice, with TBL and lectures in
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the academic sector, we have no reason to suspect participants provided data in relation to these other forms of learning. Despite being a single site study, students were employed across approximately 30 critical care units, and participants provided rich qualitative data giving weight to the findings. It is possible reflections were influenced students’ desire to please instructors and influence grades; however, marks for this 150-300 word reflection piece were 2.5% of course grade, with total marks allocated for submission and demonstration of reflection regardless of the content. Analysis was performed on deidentified reflections. 23
ACCEPTED MANUSCRIPT Recommendations for future research include tracking student reflections longitudinally, and in other disciplines given the importance of certain disciplinespecific and non-technical skills expected of graduates in any profession. The utility of TBL in clinical health areas for ongoing learning may be useful to study,
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particularly on its apparent capacity to build teamwork and professional skills.
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CONCLUSIONS
The aim of this study was to explore students’ perceptions of the role of TBL in
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shaping their learning style, team skills, and professional clinical behaviours. The majority of students expressed the belief that TBL had influenced their learning style, shifting them to more active learning strategies to achieve deeper learning and capacity to articulate critical thinking and problem solving. Reflections demonstrated
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the development of team behaviours such as better communication styles, enhanced listening skills and modification of behaviours in response to giving and receiving feedback were acquired. Information shared in TBL sessions facilitated a virtuous
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cycle of feedback encouraging deep learning that increased confidence. Increased confidence improved deep learning that, in turn, led to the development of
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professional and clinical behaviours characteristic of high quality nursing practice.
Conflicts of interest: none
Funding: A Deakin University School of Nursing and Midwifery small research grant ($4000) supported employment of a research assistant.
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References Aiken, L., Sloane, D., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E., McHugh, M., MorenoCasbas, M.T., Rafferty, A., Schwendimann, R., Scott, P.A., Tishelman, C., van Achterberg, T., Sermeus, W., 2014. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet 383, 1824-1830. doi:10.1016/S0140-6736(13)62631-8 Australian College of Critical Care Nurses, 2006. ACCCN Position statement (2006) on the provision of critical care nursing education. Australian College of Critical Care Nurses, Melbourne. Available: http://www.acccn.com.au/documents/item/19 [Accessed July 20, 2016]. Australian Council for Safety and Quality in Health Care, 2005. National Patient Safety Education Framework, Barton, ACT. Available: www.safetyandquality.gov.au [Accessed October 24, 2011]. Barrie, S., Hughes, C., Crisp, G., Bennison, A., 2012. Assessing and assuring Australian graduate learning outcomes: principles and practices within and across disciplines. Available: https://www.itl.usyd.edu.au/projects/aaglo/pdf/SP101879_FINAL%20sydney%20barrie%20final%20report%20part%201.pdf [Accessed November 22 2015]. Barrows , H., 1996. Problem-based learning in medicine and beyond: A brief overview. New Directions for Teaching and Learning 68, 3- 12. doi:10.1002/tl.37219966804 Biggs, J., Tang, C., 2011. Teaching for quality learning at university: what the student does, 4th ed. McGraw Hill: Society for Research into Higher Education & Open University Press, Maidenhead, England. Buchan, J., Aiken, L., 2008. Solving nursing shortages: a common priority. Journal of Clinical Nursing 17, 3262-3268 3267p. doi:10.1111/j.1365-2702.2008.02636.x Clark, M., Nguyen, H., Bray, C., Levine, R., 2008. Team-based learning in an undergraduate nursing course. Journal of Nursing Education 47, 111-117. College of Emergency Nursing Australasia, 2013. Practice Standards for the Emergency Nursing Specialist, Hobart, Australia. Available: http://www.cena.org.au/wpcontent/uploads/2014/10/Practice_Standards_for_the_Emergency_Nurse_Sp ecialist_June_14.pdf [Accessed 16 May 2016]. Collins, S., Hewer, I., 2014. The impact of the Bologna process on nursing higher education in Europe: A review. International Journal of Nursing Studies, 150. doi:10.1016/j.ijnurstu.2013.07.005 Currey, J., Eustace, P., Oldland, E., Considine, J., Glanville, D., Story, I., 2015a. Developing professional attributes in critical care nurses using Team-Based Learning. Nurse Education in Practice 15, 232-238. doi:10.1016/j.nepr.2015.01.011 Currey, J., Oldland, E., Considine, J., Glanville, D., Story, I., 2015b. Evaluation of postgraduate critical care nursing students' attitudes to, and engagement with, Team-Based Learning: A descriptive study. Intensive & Critical Care Nursing 31, 19-28. doi:10.1016/j.iccn.2014.09.003 Currey, J., White, K., Rolley, J., Oldland, E., Driscoll, A., 2015c. Development of a postgraduate interventional cardiac nursing curriculum. Australian Critical Care 28, 184-188. doi:10.1016/j.aucc.2015.01.003 Elo, S., Kyngäs, H., 2008. The qualitative content analysis process. Journal of 25
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Advanced Nursing 62, 107-115. doi:10.1111/j.1365-2648.2007.04569.x Fatmi, M., Hartling, L., Hillier, T., Campbell, S., Oswald, A.E., 2013. The effectiveness of team-based learning on learning outcomes in health professions education: BEME Guide No. 30. Medical Teacher 35, e1608e1624. doi:10.3109/0142159X.2013.849802 Feingold, C., Cobb, M., Givens, R., Arnold, J., Joslin, S., Keller, J., 2008. Student perceptions of team learning in nursing education. Journal of Nursing Education 47, 214-222. Feletti, G., 1993. Inquiry based and problem based learning: how similar are these approaches to nursing and medical education? Higher Education Research & Development 12, 143-156. doi:10.1080/0729436930120203 Frank, J., Brien, S.E., on behalf of The Safety Competencies Steering Committee, 2008. The safety competencies: enhancing patient safety across the health professions. Canadian Patient Safety Institute, Ottawa, ON. Available: http://www.patientsafetyinstitute.ca/English/toolsResources/safetyCompetenci es/Documents/Safety%20Competencies.pdf [Accessed February 11, 2015]. Gallegos, P.J., Peeters, J.M., 2011. A measure of teamwork perceptions for teambased learning. Currents in Pharmacy Teaching and Learning 3, 30-35. Haber, S., Boomershine, V., 2015. Opinion: An elective course in evidence-based health care using team-based learning. Currents in Pharmacy Teaching and Learning 7, 259-264. doi:10.1016/j.cptl.2014.11.004 Haidet, P., Levine, R., Parmelee, D., Crow, S., Kennedy, F., Kelly, P., Perkowski, L., Michaelsen, L., Richards, B., 2012. Guidelines for reporting team-based learning activities in the medical and health sciences education literature. Academic Medicine 87, 292-299. Harmon, R., Hills, R., 2015. Transforming psychiatric mental health nursing education with Team Based Learning. Archives of Psychiatric Nursing, 6, 413. doi:10.1016/j.apnu.2015.06.014 Hazel, S.J., Heberle, N., McEwen, M.M., Adams, K., 2013. Team-based learning increases active engagement and enhances development of teamwork and communication skills in a first-year course for veterinary and animal science undergraduates. Journal Of Veterinary Medical Education 40, 333-341. doi:10.3138/jvme.0213-034R1 Imazeki, J., 2015. Getting students to do economics: An introduction to TeamBased Learning. International Advances in Economic Research 21, 399. doi:10.1007/s11294-015-9541-0 Institute for Healthcare Improvement, 1998. Knowledge domains for health professional students seeking competency in the continual improvement and innovation of health care. Institute for Healthcare Improvement, Boston, MA. Available: http://www.ihi.org/education/ihiopenschool/resources/Assets/Publications%20 -%20EightKnowledgeDomainsforHealthProfessionalStudents_5216cd8e1867-4c77-90b6-955641ecab78/KnowledgeDomains.pdf [Accessed September 20, 2016]. Institute of Medicine, 2003. Health Professions Education: A Bridge to Quality, Washington, DC. Available: https://www.ncbi.nlm.nih.gov/pubmed/25057657 [Accessed Septemer 20, 2016]. Kelly, P., Haidet, P., Schneider, V., Searle, N., Seidel, C., Richards, B., 2005. A comparison of in-class learner engagement across lecture, problem-based learning, and team learning using the STROBE Classroom Observation Tool. 26
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Teaching and Learning in Medicine 17, 112-118. doi:10.1207/s15328015tlm1702_4 Koles, P., Stolfi, A., Borges, N., Nelson, S., Parmelee, D., 2010. The impact of teambased learning on medical students' academic performance. Academic Medicine 85, 1739-1745. Levett-Jones, T.L., 2005. Self-directed learning: implications and limitations for undergraduate nursing education. Nurse Education Today 25, 363-368. Levine, R., O'Boyle, M., Haidet, P., Lynn, D., Stone, M., Wolf, D., Paniagua, F., 2004. Transforming a clinical clerkship with team learning. Teaching and Learning in Medicine 16, 270-275. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic inquiry. Sage, Beverly Hills, CA. Macke, C., Taylor, J., Taylor, J., Tapp, K., Canfield, J., 2015. Social Work Students’ Perceptions of Team-Based Learning. Journal of Teaching in Social Work 35, 454-470. doi:10.1080/08841233.2015.1090520 Mays, N., Pope, C., 2000. Quality in qualitative health care, in: Pope, C., Mays, N. (Eds.), Qualitative research in health care BMJ Books, London, pp. 89-101. Mennenga, H., 2013. Student engagement and examination performance in a Team-Based learning course. Journal of Nursing Education 52, 475-479 475p. doi:10.3928/01484834-20130718-04 Michaelsen, L., Parmelee, D., McMahon, K., Levine, R., 2008. Team-based learning for health professions education: A guide to using small groups for improving learning. Stylus Publishing, Sterling, Virginia. Michaelsen, L., Sweet, M., 2011. Team-Based Learning. New Directions for Teaching and Learning 128, 41-51. Morris, J., 2016. The use of team-based learning in a second year undergraduate pre-egistration nursing course on evidence-informed decision making. Nurse Education in Practice 21, 23-28. doi:10.1016/j.nepr.2016.09.005 National Institute for Learning Outcomes Assessment (NILOA), 2012. Available: http://www.learningoutcomeassessment.org/AboutUs.html. [Accessed November 22, 2015]. Norman, J., 2012. Systematic review of the literature on simulation in nursing education. ABNF Journal, 23, 24-28. Nursing and Midwifery Board of Australia, 2016. Registered nurse standards for practice. Available: http://www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Professional-standards.aspx. [Accessed September 15, 2016]. Oldland, E., Currey, J., Glanville, D., Considine, J., 2012. Industry educators’ perceptions of student outcomes arising from Team-Based Learning, Higher Education Research and Development Conference, Hobart, Tasmania. Oliver, B. 2011. Assessing graduate outcomes. 2015. Available: http://www.assuringlearning.com/resources/Assuring_graduate_outcomes_AL TC_Good_practice_report.pdf [Accessed September 15, 2016]. Park, H., Kim, C., Park, J., Park, E., 2015. Effects of team-based learning on perceived teamwork and academic performance in a health assessment subject. Collegian 22, 299-305. doi:10.1016/j.colegn.2014.05.001 QSR International Pty Ltd., 2012. NVivo qualitative data analysis software. Version 10. Roh, Y., Lee, S., Choi, D., 2015. Learner perception, expected competence, and
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satisfaction of Team-Based Learning in korean nursing students. Nursing Education Perspectives 36, 118-120 113p. doi:10.5480/13-1200 Schneider, Z., Whitehead, D., Elliott, D., Lobiondo-Wood, G., Haber, J., 2007. Nursing and Midwifery Research. Methods and Appraisal for Evidence-Based Practice 3rd ed. Mosby Elsevier., Marrickville. Sisk, R.J., 2011. Team-based learning: Systematic research review. Journal of Nursing Education 50, 665-669. doi:10.1111/j.1744-6198.2009.00162.x Tucker, J., Brewster, M., 2015. Evaluating the effectiveness of Team-Based Learning in undergraduate criminal justice courses. Journal of Criminal Justice Education 26, 446-470. doi:10.1080/10511253.2015.1052000 World Health Organization Core Team, 2011. Patient Safety Curriculum Guide: Multi-professional Edition. World Health Organization, Geneva, Switzerland. Available: http://www.who.int/patientsafety/education/curriculum/en/ [Accessed october 20, 2016] Wozniak, H., Mahony, M., Everingham, F., Poulos, A., Reid, B., 2005. Inquiry based learning in the health sciences: countering the limitations of 'Problem Based' Learning [online]. Focus on Health Professional Education: A Multi-disciplinary Journal, 7, 18-30.
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S1471-5953(17)30198-1
DOI:
10.1016/j.nepr.2017.03.008
Reference:
YNEPR 2205
To appear in:
Nurse Education in Practice
Received Date: 26 January 2016 Revised Date:
1 November 2016
Accepted Date: 28 March 2017
Please cite this article as: Oldland, E., Currey, J., Considine, J., Allen, J., Nurses’ perceptions of the impact of team-based learning participation on learning style, team behaviours and clinical performance: An exploration of written reflections, Nurse Education in Practice (2017), doi: 10.1016/ j.nepr.2017.03.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT NURSES’ PERCEPTIONS OF THE IMPACT OF TEAM-BASED LEARNING PARTICIPATION ON LEARNING STYLE, TEAM BEHAVIOURS AND CLINICAL PERFORMANCE: AN EXPLORATION OF WRITTEN REFLECTIONS
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Author names and affiliations Elizabeth Oldland1 Professor Judy Currey1 Professor Julie Considine1 Josh Allen1
Deakin University, Geelong, School of Nursing and Midwifery, 221 Burwood Hwy,
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1
Burwood, Victoria, Australia, 3125
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Email: [email protected]; [email protected]; [email protected]; [email protected]
Corresponding Author: Elizabeth Oldland, Deakin University, Geelong, School of Nursing and Midwifery, 221 Burwood Hwy, Burwood, 3125, Victoria, Australia.
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Word Count: 5450
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[email protected]. +61 3 92446608
Funding acknowledgement: A Deakin University School of Nursing and Midwifery small
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research grant ($4000) supported employment of a research assistant.
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Abstract Team-Based Learning (TBL) is a teaching strategy designed to promote problem solving,
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critical thinking and effective teamwork and communication skills; attributes essential for safe healthcare. The aim was to explore postgraduate student perceptions of the role of TBL in shaping learning style, team skills, and professional and clinical behaviours.
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An exploratory descriptive approach was selected. Critical care students were invited to provide consent for the use for research purposes of written reflections submitted for course
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work requirements. Reflections of whether and how TBL influenced their learning style, teamwork skills and professional behaviours during classroom learning and clinical practice were analysed for content and thematic analysis.
Of 174 students, 159 participated. Analysis revealed three themes: Deep Learning, the adaptations students made to their learning that resulted in mastery of specialist knowledge;
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Confidence, in knowledge, problem solving and rationales for practice decisions; and Professional and Clinical Behaviours, including positive changes in their interactions with colleagues and patients described as patient advocacy, multidisciplinary communication
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skills and peer mentorship.
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TBL facilitated a virtuous cycle of feedback encouraging deep learning that increased confidence. Increased confidence improved deep learning that, in turn, led to the development of professional and clinical behaviours characteristic of high quality practice.
ACCEPTED MANUSCRIPT Keywords: Critical care nursing; Learning style; Nursing education; Team-Based Learning Highlights Team-Based Learning develops active learning styles and positive professional behaviours
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•
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Develops deep learning, increasing confidence
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Expressed as improved patient advocacy and multidisciplinary communication
Supports development of knowledge, skills and behaviours for quality
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•
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skills
healthcare
INTRODUCTION
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Nurses, as the largest healthcare workforce, play a pivotal role in the provision and coordination of care, prevention of adverse events, and optimisation of health service productivity and patient outcomes (Aiken et al., 2014; Buchan and Aiken, 2008).
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Over the last two decades, a core set of health professional competencies designed to encapsulate knowledge skill and behaviours in a safety and quality framework has
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emerged (Australian Council for Safety and Quality in Health Care, 2005; Frank et al., 2008; Institute for Healthcare Improvement, 1998; Institute of Medicine, 2003; World Health Organization Core Team, 2011). These competencies are considered as important to curricula as they are to clinical practice (Currey et al., 2015c). In tertiary education institutions across Australia, Europe and the US, incorporating teaching and assessment practices that develop and assess generic attributes are considered essential (Barrie et al., 2012; Collins and Hewer, 2014; National Institute for Learning Outcomes Assessment, 2012). Such higher degrees ensure that 1
ACCEPTED MANUSCRIPT generic skills highly valued by employers are taught along with discipline specific content. Indeed, generic attributes common to most universities include written and oral communication, critical and analytical thinking, problem solving, information literacy, learning and working independently and collaboratively, and ethical and
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inclusive engagement with communities, cultures and nations (Oliver, 2011).
Nursing education must be designed to produce graduates who are equipped with generic skills, and discipline specific knowledge and skills that meet the needs of
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their patients. There is mounting evidence that well developed communication and
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reflection skills along with effective team behaviours are central to the delivery of safe and high quality care, reducing the risk of error in health care, and improve health outcomes and patient experiences (World Health Organization [WHO], 2011). Various approaches have been implemented in health education to support acquisition of these skills, including problem based learning (Barrows 1996), inquiry
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based learning (Feletti, 1993), self-directed learning (Levett-Jones, 2005), and simulation (Norman, 2012). Each has its own strengths and limitations (Levett-Jones,
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2005; Wozniak et al., 2005). Cognizant of the imperative to better prepare registered nurses for the demands of critical care specialty practice areas, in 2009 the faculty of
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an Australian University introduced Team-Based Learning (TBL) (Michaelsen et al., 2008) into the curriculum of a postgraduate specialist critical care nursing programme. This educational strategy was selected to accelerate students’ attainment of learning outcomes requiring higher order critical thinking and problem solving skills, and to enhance graduate employability and patient safety through the development of teamwork, reflection and communication skills.
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ACCEPTED MANUSCRIPT BACKGROUND Team-Based Learning uses instructional principles that maximise student preparation and participation, which in turn foster high levels of team performance.
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Students are held accountable for their own learning before and during class, spend class time applying newly acquired knowledge to real clinical problems, and develop team and communication skills through the creation of essentially self-managed high performing teams (Kelly et al., 2005; Michaelsen et al., 2008; Michaelsen and Sweet,
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2011).
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All TBL material is designed utilising the process of backwards design (Biggs and Tang, 2011), commencing with writing intended learning outcomes for the module, providing resources that will assist the students to meet the outcomes, and developing assessment questions that allow students to demonstrate mastery of the
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learning outcomes. The strategy consists of a repeating sequence of four phases (summarised in Table 1). In Phase 1, students undertake pre-learning prior to coming to class using instructor provided resources or direction informed by clear
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intended learning outcomes. In Phase 2, the readiness assurance process, students undergo an individual multiple choice test of the topic’s core concepts. This is
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conducted at the beginning of the class and scores are submitted for grading. Before the answers are discussed, students take the same test as a member of a preformed and ongoing team of 5-7 members. Teams are allocated by the instructor to ensure team diversity based on specialty stream and place of employment. Team members come to agreement on each answer, requiring articulation and defence of their a position, and teams receive instant feedback on their chosen answer through the use of “scratch off” cards to reveal the correct answers. The Phase 2 scores are submitted and graded. This phase provides an incentive to prepare and contribute to 3
ACCEPTED MANUSCRIPT the team. In Phase 3, the team apply knowledge acquired and demonstrated through Phases 1 and 2 to a number of authentic problems (applications). Teams must make a specific choice and simultaneously report their team’s answer at which point the teacher facilitates an inter-team discussion. This phase promotes a vigorous
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discussion with students defending or refining their position in response to inter-team debate. This process, plus periodic formative and summative peer evaluation of each team member’s contribution and team behaviours (Phase 4), promotes depth of
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knowledge, problem solving skills, and positive personal and team behaviours
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(Haidet et al., 2012).
Table 1 Phases of Team-Based Learning PHASE 2
Pre-class learning
Readiness Assurance Process
• Individual test answers submitted for grading • Teams take test and reach consensus by discussion • Team answers submitted and graded • Instructor feedback
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• Study materials provided, including instructorset learning objectives
Individual and team multichoice test
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Independent student learning
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PHASE 1
PHASE 3
PHASE 4
Application of course concepts
Peer evaluation
In class team assignment
Formative and summative
• Cooperative problem solving • Instructorfacilitated class discussion between teams
Adapted from Currey et al. 2015a and Michaelsen and Sweet, 2011)
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ACCEPTED MANUSCRIPT There is a volume of TBL research that demonstrates improved student engagement and attitudes to teamwork, and a preference for this teaching strategy over didactic teaching (Clark et al., 2008; Currey et al., 2015a; Currey et al., 2015b; Haber and Boomershine, 2015; Hazel et al., 2013; Imazeki, 2015; Levine et al., 2004; Macke et
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al., 2015; Morris, 2016; Park et al., 2015; Roh et al., 2015; Tucker and Brewster, 2015). There is some evidence that students undertaking TBL have improved
academic performance (Harmon and Hills, 2015; Koles et al., 2010). However the
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evidence of sustained or higher learning outcomes assessed in test format is not conclusive as illustrated in two systematic reviews (Fatmi et al., 2013; Sisk, 2011).
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Most TBL research involves undergraduate students in the academic setting and most participants studied are not yet qualified or employed in their discipline. There are inherent and significant difficulties with trying to measure the real learning and performance outcomes of TBL in any graduate. Results of a recent qualitative study
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conducted by the authors demonstrated that industry educators believed graduates of courses using TBL displayed a range of graduate attributes not recognised in graduates of non-TBL courses (Oldland et al., 2012). However, student perceptions
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of how TBL shapes the development of graduate attributes such as communication,
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teamwork and reflection skills, and the impact of this on professional behaviour is unknown. Postgraduate nursing students are employed concurrently in industry, and thus provide good measure of the impact of TBL on graduate attributes in practice. RESEARCH AIM
The aim of this study was to explore student perceptions of the role of Team-Based Learning in shaping their learning style, team skills, and professional clinical behaviours.
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ACCEPTED MANUSCRIPT METHODS Study Design An exploratory, descriptive research design was used to address the study aim.
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Setting and Sample The study was undertaken during 2012 and 2013 in the specialty practice courses (Intensive Care, Cardiac Care, Emergency Care, and Critical Care) nested within the
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Master of Nursing Practice in an Australian University. To gain a specialist
qualification, critical care qualifications are completed over 1 to 2 years, with the
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University delivering theoretical content while nurses are concurrently employed in specialty units of hospitals. Students are supervised by hospital employed clinical nurse educators who provide clinical support and perform clinical assessments, thus ensuring the application of theory to practice in complex, highly demanding workplaces. Registered nurses must undertake four specialist units within an
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academic year. These units are embedded within a broader 12 unit Master’s degree. Each TBL session was conducted on a study day, on alternate weeks, for two
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sequential 12 week semesters. There were a total of 12 sessions each lasting 2 hours. Non-TBL sessions were delivered using didactic teaching methods and
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tutorials at other times on each study day. Each TBL session addressed core, complex topics within the curriculum such as advanced haemodynamics, temporary pacing, and shock. Students stayed in the same team for a semester then formed a new team for the second semester. Each session was facilitated by two of four trained TBL facilitators depending on content expertise. We incorporated all seven core elements of TBL: team formation, readiness assurance (RA), immediate feedback, sequencing of in-class problem solving, the four S’s (significant and same
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ACCEPTED MANUSCRIPT problem, specific choice, and simultaneous reporting), incentive structure, and peer review (Haidet et al., 2012). In accordance with published guidelines for the reporting of TBL research (Haidet et al., 2012), an overview of the inclusion and operationalisation of the seven core elements of TBL is provided in an online
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Supplementary File.
Reflective practice is a key course, university and discipline specific graduate
learning outcome and an essential professional behaviour for safe and high quality
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patient care (Nursing and Midwifery Board of Australia [NMBA], 2016). For this
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reason, the development and assessment of this skill is purposefully embedded throughout our course and intentionally assessed, including through TBL. As part of their TBL course work, all students are asked to submit a short written reflection. The question prompt for reflection is “What (if anything) have you learned about yourself as a learner, team member and clinical nurse as a result of participating in Team-
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Based Learning?” The item is due on the last day of the course and is submitted electronically to the Course Leader via email. This piece contributes 2.5% to the
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course grade. The assessment criteria for allocation of this 2.5% are that the reflection is approximately 150-300 words and demonstrates evidence of reflection. It
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is made very clear, both verbally and in written instruction that students are expected to be honest, and may well reflect that TBL has no influence at all. All students participating in TBL in two consecutive years of specialist graduate certificate courses (Intensive care, Cardiac care, Emergency care, Critical care), embedded within the Master of Nursing Practice (N = 174 students) were eligible to participate in the study (census sampling).
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ACCEPTED MANUSCRIPT Data Collection and Procedure In the week after the assessment requirement was explained to students, a member of the research team (JA) who had no teaching or assessment responsibilities in the course invited all students to participate by giving consent for the use of their
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submitted written reflection for research purposes. Students were informed that
participation was voluntary and their choice to participate or not could in no way influence their marks or relationship with any member of the teaching staff who
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would have no knowledge of a student’s participation status. Information about the
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study was also provided in a written plain language statement. Consent to participate was by return of a signed consent form and non-identifiable demographics information to JA in the classroom or via post. The Course Leader forwarded by email all students’ reflections to JA who then ‘cut and paste’ into an excel spreadsheet the deidentified reflections of the students who had provided consent to
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participate in the research project. Each participant’s reflection was given a code number. After course completion and release of final results, JA provided the deidentified data of participating students to all members of the research team. This
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process was engaged to protect participants’ anonymity and addressed the potential
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power imbalance by removing the staff members who teach and assess in the course from the stages of communicating information about the research and data collection phases of the project. There were no exclusion criteria. Ethics approval for the study was granted by the University Human and Research Ethics Committee. Participants’ consent forms were stored in a locked filing cabinet in a locked University office.
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ACCEPTED MANUSCRIPT Data Analysis First pass data analysis was performed on deidentified data by a research assistant (JA) who was not a member of the teaching team. Participant reflections were analysed using the established complementary techniques of thematic and content
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analysis (Elo and Kyngäs, 2008; Lincoln and Guba, 1985). A qualitative data
analysis software package, NVivo (2012) was used to store and manage data. Content analysis techniques combined deductive and inductive techniques to
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identify themes, and resulted in final themes that are both descriptive and
explanatory. Initial results were analysed for overlap, redundancy, emergence of
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any new themes, and relationships between themes (Lincoln and Guba, 1985) by three members of the research team (EO, JCu and JA). Peer collaborations, peer debriefing, rich thick descriptions of data and open transparency about research aims enhanced the rigor of the research (Lincoln and Guba, 1985; Mays and Pope,
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2000; Schneider et al., 2007). As the reflections were deidentified, member checking was not possible.
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FINDINGS
Of the sample, 172 consented to participate (99% response rate); however, only 159
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subsequently submitted a written reflection (91% response rate). Demographic data are presented in Table 2. The majority of the participants were female (90%) aged 26-30 (38%), with between 3 and 5 years’ experience as a registered nurse (59%). Of those years as a registered nurse, 2 to 3 years were in a specialty practice setting (51%).
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ACCEPTED MANUSCRIPT Table 2. Participant demographics
18 154
10 90
48 65 30 29
28 38 17 17
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9 102 35 23
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%
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Gender • male • female Age group (years) • 22-25 • 26-30 • 31-35 • 36+ Years as Registered Nurse (missing n=1) • 1-2 • 3-5 • 6-10 • 11+ Years in Speciality Practice (missing n=1) • 0-6 • 2-3 • 4-5 • 6+
n
26 51 11 12
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46 87 18 20
6 59 20 13
Thematic analysis of the data revealed three themes: 1. Deep Learning, 2.
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Confidence, and 3. Professional and Clinical Behaviours. The three themes are
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closely linked and interrelated (see Figure 1).
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Figure 1. Thematic analysis of participants’ reflections. 1. Deep Learning
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In Deep Learning, students reflected on the deep learning they had experienced as a result of their TBL experiences. This deep learning was attributed in the reflections to two distinct constructs: content learning and practicing for practice.
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Content learning
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The first construct was content learning, in which students reflected on the adaptations they had made to their own learning style and on their motivation to learn in the context of TBL. Many students reflected on what they saw as a need to adopt a new learning style for TBL material, including adjusting study habits. I became a more active learner after about 3 TBL sessions (R150);
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ACCEPTED MANUSCRIPT TBL has allowed me to discover that in order to learn the content I need to externalise it (R123). The students described changes to the way they studied course material when
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alone, taking a more active approach to their study (for example, explaining a concept out loud, mind mapping, and the adoption of more group based study). For many students, TBL took over as the preferred method of study.
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My learning style used to be composed of individual study with reading and learning on my own. However throughout this year of study I have found it
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increasingly hard to learn this way. I now find it challenging to learn on my own, and feel I require the group environment and ‘team’ to learn new information and to apply myself to study. Group study sessions benefit me the most, with talking out loud now my favoured way to actually feel like I am
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taking in the information being taught (R28);
TBL changed my learning style. I only studied hard before exams during my
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undergraduate study. Now, I study before every TBL session. I don't feel too
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much stress at the end of semester because most of the content has been tested during TBL. TBL shows me the study direction (R50).
For those who self-identified strongly as preferring to study alone, their original preferences remained, although they were able to adapt to the new learning style. Although, this type of learning is perhaps not suited to myself, I did learn from others' discussions and the case studies were particularly helpful to relate
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ACCEPTED MANUSCRIPT new knowledge to clinical areas. Overall, my learning style has remained the same (R4). It may be that those students who identified a preference for studying alone were
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those who had already developed sound study techniques and were accustomed to high grades.
Being motivated to learn course content was a strong finding in the reflections which
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was expressed as two distinct motivations for learning: assessment and not wanting to let the team down or to establish their credentials. Many students identified TBL
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assessments (20% of summative grades) as the main driver of learning, while others believed that being able to contribute to the team was their primary motivator. TBL weekly tests compelled me to learn the topics thoroughly (R4);
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TBL encourages a lot of independent studying, everyone would like to be a competent practitioner/student amongst our colleagues/teams
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(R52);
My desire to be an effective member of the team and not be a weak link, has added impetus for studying prior to the TBL session (R57).
A few identified ‘carrot and stick’ motivations to learning. Students wanted to ensure they had learned the content to pass/receive marks or to impress the team/establish their credentials (carrots); and didn’t want to let their team down (stick). I felt pressure to be prepared, in order to assist myself and my team in succeeding. The pressure became determination and facilitated a 13
ACCEPTED MANUSCRIPT positive learning experience. Independent learning gave me great satisfaction and a sense of pride. I could gauge my performance and gain positive and negative feedback on my level of knowledge (on)
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clinical and theoretical components (R31);
I realised from the first TBL session that I needed to come prepared to
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be able to participate and help the group get good marks along with
increasing my knowledge...It helped me study each week, as I knew I
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had to contribute to help my team (R7).
It appears that the short term incentive to learn had much more bearing on student motivation than medium or long term goals. Many noted that TBL was an effective preparation for final exams; however, students were also able to link the learning that
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took place in TBL with their clinical practice. This was illustrated in the second construct of the deep learning theme. Practicing for practice
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The second construct identified within the theme of deep learning was ‘practising for
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practice’. This was expressed by students as the learning and development of new skills through testing and justifying knowledge, small and large group communication, and teamwork skills. Students tested and rationalised their new knowledge through the process of defending and justifying their answers. This process was beneficial to learning and clarifying difficult concepts. Students valued the supportive environment where they could offer an explanation for an answer or treatment decision based on physiology or evidence. Students also valued when
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ACCEPTED MANUSCRIPT their team members sought clarification, challenged an answer or provided another viewpoint. Thus, peer feedback was essential to this theme. Knowing and understanding clinical information helped me to be more
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confident talking to doctors and others in the unit, be confident about my answers to their questions, or have an idea or where to find the answers to them if I didn’t know. I’m much more confident about being able to look at the patient as a whole person, rather than just looking at parts of them;
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connecting data to make a whole picture instead of just looking at the
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information separately (R29);
While finding the questions very challenging, being able to provide a rationale for "why wasn't answer 'a' correct?" that seemed to really cement to me that
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even if I was not entirely sure of the answer I could still provide a rationale for why I may not have chosen a particular answer (R41);
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I found TBL helpful to improve my knowledge. Having to talk through the
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answer and explain my reasoning to others meant that I found I had good knowledge on the topic (R13).
By testing and justifying knowledge in the TBL environment, they learned course content; that is, discipline specific knowledge more deeply and ‘practiced for practice’. Rehearsing verbal rationale clarified and reinforced understanding. Participants made clear links between this ‘practicing’ and the requirement for this level of understanding and articulation in the clinical environment.
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ACCEPTED MANUSCRIPT Unless I can explain my ideas well to my teammates, I have never really understood the basic concepts of that topic well enough, because my ideas
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can be easily challenged by the others (R47);
TBL helped me learn things in a manner I clearly understand. I am able to explain in a clear and succinct manner to my fellow team members, the
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educators in my clinical area and all other members of the multidisciplinary team at work. My confidence in what I say has increased markedly and I the
has been great (R41).
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directors of my unit ask me more questions during the medical round which
Many students commented they had learned more about themselves through peer evaluation. Peer evaluation in TBL is designed to provide feedback, develop
unhelpful behaviours.
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reflective and peer evaluation skills, reinforce positive behaviours, and modify
TBL and peer evaluation has taught me that I can be quite overpowering and
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forthright in defending my views and that sometimes I need to step back and
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invite the opinions of other colleagues (R142). Several students were disarmingly honest about peer feedback that highlighted poor communication; for example, speaking over others, interrupting and discouraging other views. For these students, structured, honest, timely and respectful peer feedback was transformative in improving their communication skills.
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ACCEPTED MANUSCRIPT 2. Confidence In the second theme students reflected on the increased confidence acquired through improved knowledge and problem solving skills, and articulation of rationales for practice decisions. They reported increased confidence in their own clinical
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knowledge and communication skills in class and clinical environments.
What gives me confidence in speaking up is an in-depth knowledge on the subject, and as the year has gone on and my own knowledge base has
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increased, it has become much easier to be able to stand up and say my
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piece - I think that in part is due to actually understanding the topics (R53);
It helped me realise that I should have more confidence and knowledge to be able to speak up more confidently when I know I am speaking the right matter
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and should be able to convince the other person with a valid rationale (R39).
Students often made the link between the deep learning of content and having
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confidence in their knowledge, speaking in TBL and speaking with other clinicians in
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their workplace such as the ward round.
My level of confidence grew and public speaking became part of the learning experience, and has assisted me in my workplace to approach senior medical staff and maintain my role as a patient advocate in any situation (R170);
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ACCEPTED MANUSCRIPT Having a wider knowledge base from participating in TBL, I now have more confidence to question patient management plans and be a more active member of a multidisciplinary team (R6).
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Students’ fear of being 'wrong' was allayed, giving students the confidence to speak up, both in class and in a multi-disciplinary clinical context. Students also described occasions when they did not have the confidence to speak up, despite feeling that
SC
they had the correct answer. This was sometimes attributed to confidence in
speaking up, fear of being wrong, or on other group members not creating the
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opportunity.
My main problem was my lack of confidence to say what I think as I was too afraid that I might be wrong. It annoyed me even more when I was right that I didn't try hard enough to make my points heard…but then the more TBL we
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did in class the more confident I felt and a little better I got at explaining things to others. As the comfort built up in the group I was more able to say what I
EP
thought (R60);
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Initially it was bit overwhelming for me because I found it little hard to express myself in front of huge class as I am not a very good speaker generally. But as the course went on, I found myself speaking. And that helped me develop confidence while having discussions with the medical team (R1).
Confidence was an outcome of TBL that reinforced deep learning (theme 1) which in turn translated into professional and clinical behaviours (theme 3).
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ACCEPTED MANUSCRIPT 3. Professional and Clinical Behaviours The third theme identified was Professional and Clinical Behaviours. Professional behaviours included leadership, role-modelling and teamwork skills; the development of which many attributed to TBL. A number of students reflected they had learnt or
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discovered innate leadership skills during TBL. Students reflected that they were beginning to act as role-models in their workplace. Clinical skills gained from TBL included patient advocacy, contribution to team decisions, and quality nursing care.
SC
I have found my voice in nursing. I take a more active part in the decision
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making process of patient care. I ask questions if I’m not sure about why certain decisions are made, I make suggestions and colleagues listen (R116);
TBL certainly developed my listening and negotiating skills and I can see this
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being beneficial to resolve conflict within the department. TBL has also made me aware of the role of teamwork within critical care nursing, that collaboration is essential to provide excellent patient care and develop lasting
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profession relationships with colleagues (R11);
I learnt to trust myself, to trust what I knew and not to be scared to speak up if I didn’t necessarily agree. It has transferred over to my clinical area where I no longer just take orders from doctors, but rather take an active part in the decision making process of patient care. I ask questions if I’m not sure about why certain decisions are made, I make suggestions and colleagues listen. I have found my voice in nursing, and I truly believe it can only get better with time (R25).
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ACCEPTED MANUSCRIPT A number of students reflected that they had learnt or discovered leadership skills during TBL. A number of students also reflected that they were beginning to act as role-models at work. I have learnt valuable lessons about my role in a group and found to my
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surprise that I no longer sit back but am capable of being a leader within a group. This is a result of the self confidence that acquiring in-depth knowledge
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brings and I am a much better clinical nurse as a result (R11);
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I have changed and grown as an individual and my nurse colleagues now seek my opinion on best practice issues in ward, which I find a privilege that I’m now a valued Team member, and my opinion matters (R12);
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I have discovered that I have some natural leadership abilities and I think these have developed during TBL (R56).
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For others, it was a reflection on their own position in the workplace, the contribution
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they made to improvements in evidence-based practice, and their acceptance of their professional responsibility to assist other staff to provide safe and high quality care.
TBL has changed me to challenge poor practice and initiate evidence-based practice in clinical area (R37);
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ACCEPTED MANUSCRIPT TBL regularly focused on evidence-based practice which fuelled my enthusiasm in transferring evidence-based practice to the bedside and
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assisted my development to become a better advocate for my patients (R55);
TBL also helped the patient clinical presentation was not cut and dry. I am able to teach evidence to other nurses and have the confidence to do so (R2).
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Finally, some participants directly acknowledged they had become reflective and developed insights into their own strengths and weaknesses. Although a subjective
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review of the participants’ responses demonstrates varying levels of reflective abilities, this is consistent with the any skill development of learners. Most students reflected upon a change in learning style facilitated by TBL, while others felt that their learning style had remained unchanged, sometimes in spite of TBL.
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I don’t feel that my learning style has changed much this year. I have always really enjoyed solitary study; however, I do realise that working as a nurse and problem solving sometimes demands group work and feel I appreciate group
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EP
work more (R110);
I don’t believe that TBL has changed my communication style, which is very much about listening and respecting the opinions of others, as well as having an opinion myself to put forward. It has however helped my confidence level in communicating effectively to small and large groups (R158).
Some students referred to TBL only as a tool for learning whereas others were able to see the implications this learning method had on their clinical and professional
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ACCEPTED MANUSCRIPT practice. No student expressed an increase in their confidence to be a reflective practitioner.
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DISCUSSION This novel study sought student perceptions of how, if at all, TBL influenced their learning style, teamwork skills, and professional behaviours. This unique perspective was possible because students were studying at postgraduate level and in
SC
concurrent professional practice.
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Findings showed students attributed learning via TBL to deep learning of cognate knowledge, raised confidence as a learner and professional practitioner, and developing or improving their professional and clinical behaviours. The acquisition of critical thinking, problem solving and teamwork behaviours have been identified as
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critical to reducing patient harm improving the quality of care provided (World Health Organization Core Team, 2011). There is emerging evidence that the structure and process of TBL supports development of these attributes in undergraduate nursing
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programmes, (Clark et al., 2008; Feingold et al., 2008; Harmon and Hills, 2015; Mennenga, 2013; Park et al., 2015; Roh et al., 2015) and more recently in
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postgraduate nursing (Currey et al., 2015a; Currey et al., 2015b). Findings of this study provide further evidence from the learners’ perspectives about the value of TBL for developing and consolidating these skills. Our findings about students’ attribution to TBL for deep learning of key discipline-specific concepts and enhanced teamwork confirms that of Morris (2016) in undergraduate nursing courses. Feelings of, or growth in, student confidence have not been attributed to TBL in previous research. It is possible that confidence was a strong finding in this study
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ACCEPTED MANUSCRIPT due to students’ context of concurrent professional practice. Participants linked confidence to improved knowledge and problem solving skills, and clearly identified a virtuous cycle of confidence, knowledge, and public speaking. It is argued the provision of a safe place for students to develop these skills in a TBL classroom
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enables this cycle of professional development that students articulated so well. Participants related their increased confidence with improved patient advocacy,
interprofessional collaboration, and professional leadership behaviours. Improved
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professional team behaviours have been reported in previous TBL literature
(Gallegos and Peeters, 2011; Park et al., 2015); however, further studies are
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required to confirm findings of advocacy and leadership behaviours considering the importance of these attributes for nursing practice (Australian College of Critical Care Nurses, 2006; College of Emergency Nursing Australasia, 2013; NMBA, 2016; WHO, 2011) and safety in healthcare.
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This study has certain limitations. We do not claim a cause and effect relationship between TBL and self-reported benefits, nor conclude that students’ self-reported
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skills are demonstrated in practice. Although there were other ways in which student learnt in this course, predominantly experiential in practice, with TBL and lectures in
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the academic sector, we have no reason to suspect participants provided data in relation to these other forms of learning. Despite being a single site study, students were employed across approximately 30 critical care units, and participants provided rich qualitative data giving weight to the findings. It is possible reflections were influenced students’ desire to please instructors and influence grades; however, marks for this 150-300 word reflection piece were 2.5% of course grade, with total marks allocated for submission and demonstration of reflection regardless of the content. Analysis was performed on deidentified reflections. 23
ACCEPTED MANUSCRIPT Recommendations for future research include tracking student reflections longitudinally, and in other disciplines given the importance of certain disciplinespecific and non-technical skills expected of graduates in any profession. The utility of TBL in clinical health areas for ongoing learning may be useful to study,
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particularly on its apparent capacity to build teamwork and professional skills.
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CONCLUSIONS
The aim of this study was to explore students’ perceptions of the role of TBL in
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shaping their learning style, team skills, and professional clinical behaviours. The majority of students expressed the belief that TBL had influenced their learning style, shifting them to more active learning strategies to achieve deeper learning and capacity to articulate critical thinking and problem solving. Reflections demonstrated
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the development of team behaviours such as better communication styles, enhanced listening skills and modification of behaviours in response to giving and receiving feedback were acquired. Information shared in TBL sessions facilitated a virtuous
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cycle of feedback encouraging deep learning that increased confidence. Increased confidence improved deep learning that, in turn, led to the development of
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professional and clinical behaviours characteristic of high quality nursing practice.
Conflicts of interest: none
Funding: A Deakin University School of Nursing and Midwifery small research grant ($4000) supported employment of a research assistant.
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