The effectiveness of team-based learning on learning outcomes in health professions education: BEME Guide No. 30

Figures & data

Table

Practice points

Team-based learning appears to improve knowledge scores but yields mixed positive and negative learning reaction. Curriculum planners who do implement TBL are advised to take precautions to mitigate potentially negative learner reactions to this teaching strategy. The authors hypothesise that this may be due to increased student workload and shift in culture towards peer assessment and accountability; however, further research is needed to clarify the reasons for low learner satisfaction. TBL appears to be promising over various settings and populations within health professions education in this small group of studies. More robust, controlled primary studies, with thorough reporting and with inclusion of higher lever learning outcomes such as application skills and behaviours, would be helpful to establish a stronger evidence base for curriculum planners considering implementation of TBL.

Table 1.  Included online databases

Health-related databases	General databases
Medline (1950–present)	Physical Education Abstracts
EMBASE (1980–present)	SCOPUS (1823–present)
PubMed (1950–present)	Web of Science (1956–present)
CINAHL (1937–present)	ERIC (1966–present)
Cochrane Library  (various dates–present)	OpenSigle (various years–present)
	Proquest Dissertations and Theses (content dates vary - present)

Databases – note that all searches were limited to 1970 to current (July, 2011).

Table 2.  Search terms and strategy for health-related databases

Health trainee education methods	and “TBL”
exp Education/ or exp Educational Technology/ or “teaching method*”.mp. or curriculum.mp. or “instructional method*”.mp.	“team based learn*” or (tbl and team*)

Limits: English language, human, 1970–present

Table 3.  Search terms and strategy for general databases

Team-based learning	And “Health professions”
“team based learn*” or (TBL and team*) DE “TEAM learning approach in education"	medic* or nurs* or “physical therap*" or physician* or health or dentist* or pharmac* or “occupational therap*” or doctor* or dietitician* or psychologist* or psychiatr* or clinic* or clerkship* or veterinary*

Limits: English language, human, 1970–present.

Table 4.  Inclusion and exclusion criteria applied to potentially relevant studies to determine suitability for systematic review purposes

	Inclusion criteria	Exclusion criteria
Population	Medical Students Residents Physicians Nursing Students/Nurses Pharmacy Students/Pharmacists Dental Students/Dentists Veterinary Trainees/Veterinarians Dietician Trainees/Dieticians Clinical Psychology Trainees/Clinical Psychologists Other Allied Health Professionals Interdisciplinary health professions teams	Non-Health Professions Trainees
Intervention	Team-based learning in conjunction with: Lectures Workshops Small group learning sessions Clinical teaching Other structured teaching sessions	Shadowing Mentoring Practice audits Feedback alone
Comparator	Any teaching method described under the inclusion  criteria for Intervention section without TBL. Any “standard curriculum” without TBL
Outcome (Categorised by the modified  Kirkpatrick's 1967 model of hierarchical  outcomes (Kirkpatrick & Kirkpatrick 2006))	Change in patients’ health Change in behaviour  Inclusion of skill in clinical practice Change in skills  OSCE scores  Observed assessment scores Change in knowledge Written exam scores Change in attitudes/perceptions  Confidence self ratings  Comfort self ratings Learner Reaction  Satisfaction with teaching method  Satisfaction with instructor
Study type	Comparative studies which provide primary data  for any of the outcomes listed above, including  the following designs:  Randomised controlled trials  Non-randomised control trials  Controlled before and after studies  Interrupted time series  Other robust comparative studies (e.g. cohort studies)  Qualitative comparative studies	Studies reporting on needs assessments for TBL Studies reporting the prevalence of TBL Opinion Papers Studies without a comparator group Studies with uncontrolled before and after design
	English language (Morrison et al. 2009)	Articles not in the English language

Table 5.  Summary of findings

			Findings: Any significant difference
Outcome	Intervention	Comparator	No statement	p > 0.05	p < 0.05	Study design and number of participants enrolled
Knowledge	TBL	CBGD		No difference		RCT (n = 83)
					Favours TBL	NCC (n = unclear)
		SGL			Favours TBL	NRCT (n = 112)
					Favours TBL	NRCT (n = 167)
		Mixed Active Learning			Favours TBL	CC (n = 64)
		Independent Study	Favours TBL			PC (n = 1417)
		Traditional Lecture		No difference		NCC (n = unclear)
					Favours TBL	RC (n = 186)
			Favours TBL			NCC (n = 280*)
					Favours TBL	NCC (n = 306)
				No difference		NCC (n = 143)
					Favours TBL	NCC (n = 371)
			Favours TBL			NCC (n = unclear)
				No difference		PC (n = 121)
Reaction	TBL	CBGD		No difference		RCT (n = 83)
		SGL		No difference		NRCT (n = 112)
					Favours SGL	NRCT (n = 167)
		Mixed Active Learning		No difference		CC (n = 64)
		Traditional Lecture	Favours TBL			NCC (n = unclear)
			Favours lecture			NCC (n = 280*)
					Favours TBL	NCC (n = 306)

RCT = randomized controlled trial; NRCT = non-randomized controlled trial; NCC = non-concurrent cohort; CC = concurrent cohort; PC = prospective cohort; RC = retrospective cohort.

*The exact number of participants enrolled in the study was not reported.

Table 6.  Study characteristics

Citation	Institution	Design	Population (N)	Research question/purpose	Intervention (N)	Comparator (N)	Primary outcomes	Observed modifications to classic TBL
(Koles et al. 2005)	Wright State University School of Medicine	RCT	Undergraduate medical (83)	To evaluate the impact of TBL on the academic performance of Year 2 medical students at Wright State University by comparing this active learning strategy against a traditional method of CBGD	TBL incorporated into eight pathology modules (80)	CBGD (80)	Knowledge: final exam scores Learner reaction	Unclear if peer assessment performed
(Thomas & Bowen 2011)	Johns Hopkins University School of Medicine	NRCT	Undergraduate medical (112)	To compare the impact of TBL versus usual small group lecture (SGL) on knowledge objectives in a clinical clerkship	TBL format used in six ambulatory medicine modules (112)	Small group learning (112)	Knowledge: exam scores Learner reaction	None observed
(Willett et al. 2011)	University of Medicine and Dentistry of New Jersey	NRCT	Undergraduate medical (167)	To determine if team-based learning could be substituted for small group learning in case sessions without compromising test performance or satisfaction	Endocrinology and rheumatology module offered in TBL format (84)	Small group learning (83)	Knowledge: exam scores Learner reaction	Lectures still used to deliver content; RATs and peer assessment did not contribute to students’ grade
(Conway et al. 2010)	University of Oklahoma College of Pharmacy, Oklahoma City and Tulsa campuses	Non-concurrent cohort	Undergraduate pharmacy (N = unclear)	To integrate components of team-based learning (TBL) into a cardiovascular module to increase students’ responsibility for their own learning and actively engage students across two campuses in patient cases	Lecture-based course replaced with self-directed learning (SDL) assignments and case discussions were replaced with TBL in six sessions (140)	Traditional lecture format (N = unclear)	Knowledge: number of assigned course grades Learner reaction	No GRATs; lectures still used to deliver content
(Koles et al. 2010)	Wright State University School of Medicine	Retrospective cohort	Undergraduate medical (186)	To determine whether student performance on examinations is affected by participation in TBL and whether TBL benefits lower- or higher-performing students	TBL incorporated into 10 courses (178)	Traditional lecture format (primarily), laboratory, clinical case discussions, and independent study module (178)	Knowledge: final exam scores	Mixed curriculum includes TBL, lectures, labs and clinical sessions, to deliver content
(Letassy et al. 2008)	University of Oklahoma College of Pharmacy, Oklahoma State University Center for Health Sciences	Non-concurrent cohort	Undergraduate pharmacy (280)	To implement a team-based learning (TBL) format in an endocrine module to promote students’ active learning in a course delivered to two campuses	Endocrinology module offered in 13 TBL sessions at two campuses (140)	Traditional lecture format (140)	Knowledge: unit exam scores Learner reaction	None observed
(Levine et al. 2004)	University of Texas Medical Branch	Non-concurrent cohort	Undergraduate medical (306)	To compare students' performance and educational experiences before and after curricular change	8 of 16 lecture sessions were replaced with TBL activities; only 4 of 8 sessions implemented IRATs/GRATs (133)	Traditional lectures (primarily) and case conferences (131)	Knowledge: NBME psychiatry shelf exam scores Learner reaction	TBL slowly phased in; lectures still used to deliver content
(Mennenga 2010)	University of Nevada, Las Vegas	Non-concurrent cohort	Undergraduate nursing (143)	To examine differences in student engagement between baccalaureate nursing students taught using team-based learning and those taught using traditional lecture, and how levels of engagement affected exam scores	Lecture-based community health nursing course replaced with TBL (69)	Traditional lecture (74)	Knowledge: exam scores	None observed
(Nieder et al. 2005)	Wright State University School of Medicine	Non-concurrent cohort	Undergraduate medical (371)	To determine if students would be better prepared and find TBL more effective than previous small group sessions	12 TBL sessions incorporated into a human anatomy and embryology course (95)	Traditional lecture (276)	Knowledge: number of exam failures	Lectures also used to deliver some content
(Pileggi & O'Neill 2008)	University of Texas Health Science Center	Non-concurrent cohort	Undergraduate dental (N = unclear)	To facilitate student learning and performance in a sophomore preclinical endodontic course and improve student ability to diagnose diseases utilizing TBL combined with an audience response system	Lecture-based endodontics course replaced with TBL (64)	Traditional lecture (N = unclear)	Knowledge: final exam scores	Group size larger (10–11); unclear whether RATs were weighted in students’ final grade; GRATs were “parallel” but not identical to IRATS; description of application exercise unclear; peer assessment unclear
(Torralba et al. 2009)	University of Southern California School of Medicine	Prospective cohort	Residents (121)	To study the effectiveness and outcomes of using TBL in Rheumatology core curriculum learning sessions (CCLS) for Internal Medicine (IM) residents over an initial period of 12 months	Seven rheumatology CCLS offered in TBL format (68)	Traditional lecture (53)	Knowledge: in-training exam scores	Value of Teams Survey was conducted in place of peer assessment
(Wiener et al. 2009)	Medical University of Vienna	Prospective cohort	Undergraduate medical (1417)	To examine the impact of team-based learning (TBL) on educational outcomes in the first year of the curriculum of the Medical University of Vienna	Optional intensive review course for final exam offered in TBL format (588)	Independent study (829)	Knowledge: final exam scores	The course was an optional intensive review over a 3-day period; participants were self-selected; RATs were not assigned weight to final grade; peer assessment unclear
(Zgheib et al. 2010)	American University of Beirut Faculty of Medicine	Non-concurrent cohort	Undergraduate medical (N = unclear)	To examine the effect of teaching pharmacology using a TBL approach on second year medical students’ satisfaction and performance	TBL was incorporated into two CBGD sessions of pharmacology (N = unclear)	CBGD (N = unclear)	Knowledge: exam scores	TBL implemented in only two class sessions (short duration); student-selected groups; lectures also used to deliver content; RATs were not assigned weight to final grade; peer assessment not performed
(Zingone et al. 2010)	University of Tennessee Health Science Center College of Pharmacy	Concurrent cohort	Undergraduate pharmacy (64)	To assess students’ performance and perceptions of team-based and mixed active-learning methods in two ambulatory care elective courses	Ambulatory care elective course offered in TBL format (37)	Mixed active learning methods (27)	Knowledge: final grades Learner reaction	None observed

Table 7.  Main findings of the review

Citation	Design	Outcomes	Summary of results	Author's conclusions	Stated limitations
(Koles et al. 2005)	RCT	Knowledge: final exam scores Learner reaction	No significant differences in exam scores were found between the TBL session exams and the CBGD exams. For the immune, neoplastic, cardiovascular and parathyroid modules, the TBL group scored 80.7% and the CBGD scored 81.2% for modules INCP (p = 0.79). For the genetic, muscle, breast and liver disease modules, the TBL group scored 85.9% and the CBGD group scored 87.6% (p = 0.36). However, in the lowest academic quartile, the authors report a significantly reduced deterioration of long-term knowledge retention after experiencing a TBL session than a CBGD (−1.5% vs. −9.3%, p = 0.035). No significant difference was found between learner reaction scores (p = 0.143).	“TBL and CBGD are equally effective active learning strategies when employed in a systems-based preclinical pathology curriculum, but students with lower academic performance may benefit more from TBL than CBGD.”	TBL and CBGD are fundamentally different teaching methods.
(Thomas & Bowen 2011)	NRCT	Knowledge: exam scores Learner reaction	A significant difference was observed in exam scores between the TBL and SGL cohorts in five of six modules favouring TBL. The average TBL score for the first three modules was significantly higher than the SGL score (77.1% vs. 73.2%, p = 0.05) as well as for the second three modules (78.4% vs. 66.8%, p < 0.001). The authors reported an insignificant difference between learner reaction to the usefulness of the modules taught via TBL or SGL (4.35 vs. 4.29); no p value was given.	“This study adds to the growing body of evidence suggesting effectiveness of the TBL method in achievement of knowledge objectives for the health professional student.”	This study took place in one medical school with one faculty facilitator; expertise bias could have been introduced; the clerkship was 4 weeks, which did not allow for the optimal 40-hour investment to develop teams.
(Willett et al. 2011)	NRCT	Knowledge: exam scores Learner reaction	There was a significant difference between the exams score of TBL and SGL groups favouring TBL (81.7% vs. 79.7%, p = 0.04). However, the groups also performed significantly differently on modules in which TBL was not implemented (79.5% vs. 77.1%, p = 0.01). After adjusting for performance on the non-TBL modules, the authors reported no significant difference. Students significantly preferred SGL over TBL (3.74/5 vs. 2.45/5, p < 0.001).	“We found that a TBL approach to case-based learning was feasible and resulted in similar examination performance when compared to a concurrent SGL approach.”	The study was implemented in one course at one institution; TBL was not the only teaching strategy used; allocation to groups was not randomised; only 43% of students responded to the surveys.
(Conway et al. 2010)	Non-concurrent cohort	Knowledge: number of assigned course grades Learner reaction	No statistically significant differences were found between student performance before and after TBL implementation; however, the authors report a non-significant trend towards increasing average exam scores after implementation. The number of students receiving non-passing grades (D and F) decreased after TBL implementation (2.7% vs. 0%) and the number of students receiving B's increased (58.9% vs. 63.0). As well, the number of students receiving A's decreased after TBL (19.6% vs. 17.8%), though no p values were given. Average learner satisfaction scores are reported to have increased after TBL was implemented (4.4 vs. 4.2); no p value was given.	“Compared to pre-TBL cohort, student performance was maintained and satisfaction was increased.”	NS
(Koles et al. 2010)	Retrospective cohort	Knowledge: final exam scores	TBL-related questions were answered correctly an average of 5.9% more often than TBL-unrelated questions. 83.6% of TBL-related questions were answered correctly while 77.9% of TBL-unrelated questions were answered correctly (p < 0.001). Within the lowest academic quartile, TBL-related questions were answered correctly more often than in the highest academic quartile (7.9% vs. 3.8%, p = 0.001).	“Overall, students in two consecutive second-year classes demonstrated significantly higher performance on pathology based questions related to course content learned via TBL modules. In our opinion, a 5.9% higher mean score is large enough to be meaningful for educators.” This is the first study in medical education demonstrating that TBL provides a larger learning benefit for lower-achieving students compared with higher-achieving students.	The study was limited to pathology; did not compare TBL with another active learning strategy; and only short-term knowledge was tested.
(Letassy et al. 2008)	Non-concurrent cohort	Knowledge: unit exam scores Learner reaction	Though no p value or statistical difference was reported, the TBL cohort scored higher than the lecture cohort (86% vs. 81%). Learner reaction scores were lower for TBL (3.5/5 vs. 4.6/5); no p value was given.	“TBL effectively covers course content without sacrificing grades. The repetitive nature of the TBL process appears to provide the most benefit to academically weak students due to the increased structure and accountability for learning.”	NS
(Levine et al. 2004)	Non-concurrent cohort	Knowledge: NBME psychiatry shelf exam scores Learner reaction	There was a significant increase in NBME psychiatry subject exam scores between the TBL cohort and lecture cohort (72.9% vs. 69.6%, p < 0.05). There was also a significant difference in learner reaction favouring TBL (3.68/5 vs. 3.21/5, p < 0.001).	“The results suggest that team learning activities could be an important addition to traditional clerkship didactic programs in medical education. Attainment of core knowledge, as determined by NBME subject test scores, was significantly higher than in the previous curriculum. Team learning activities were perceived to be significantly more effective and enjoyable.”	Gathering controls from previous academic year is not ideal; attitudes could have been influenced by different faculty.
(Mennenga 2010)	Non-concurrent cohort	Knowledge: exams scores	No significant difference was found on exam scores for four exams between the TBL group and lecture group (41.32/50, 42.26/50, 31.39/40, 49.72/60 vs. 40.99/50, 39.07/50, 34.85/40, 49.66/60, p = 0.923).	While some findings did not suggest team-based learning to be better than traditional lecture, the findings regarding examination scores do suggest that team-based learning is at minimum equally as effective as traditional lecture.	The population size of 143 is relatively small; the author had limited experience with TBL; differences could have existed between the control and experimental groups; the validity of instrument assessing the effectiveness of TBL is relatively new.
(Nieder et al. 2005)	Non-concurrent cohort	Knowledge: number of exam failures	There was a significant decrease in the number of exam failures after the implementation of TBL compared to the lecture group (1 vs. 6, p < 0.001). The authors reported no significant difference between the average exam scores before and after TBL implementation (p = 0.344).	Although the class's grade average was similar to previous years’ averages, we believe that the team-based learning did help the few academically weaker students to succeed.	NS
(Pileggi & O'Neill 2008)	Non-concurrent cohort	Knowledge: final exam scores	The final exam scores increased after the implementation of TBL compared to the didactic lecture group one and two years prior (75% vs. 69% and 56%, respectively); no p value was given.	“The course faculty believe that this methodology improved students’ didactic knowledge as well as their diagnostic skills when in clinic. We believe that using TBL enhanced our students’ skills on differential diagnosis and hopefully prepared them for success in their daily clinical education experience.”	NS
(Torralba et al. 2009)	Prospective cohort	Knowledge: in-training exam scores	The average exam scores for residents in the TBL group were slightly higher than the didactic lecture group, but did not reach significance (54.4% vs. 50.7%, p = 1.10). The authors also analysed the differences between the groups by year of residency and found a significant difference at the PGY1 level (p = 0.03), though no significant differences were found at the PGY2 or PGY3 levels.	“Internal medicine residents are receptive to the use of TBL for CCLS, and have favourable perceptions of collaborative learning. Additionally, results provide information on potential impact of TBL on available assessments such as the ITE.”	NS
(Wiener et al. 2009)	Prospective cohort	Knowledge: final exam scores	Students who elected to take the TBL review course scored 18.3% higher than the students who did not (137/230 vs. 116/230); no p value was given. The students who took the TBL course also had a 16.5% higher score in the remaining five non-TBL blocks of the year when compared to the students who did not take the elective.	“Providing TBL as an elective fosters a positive selection of the best students of the year making them even more successful on the final exam.”	The students self-selected to take the elective TBL course.
(Zgheib et al. 2010)	Non-concurrent cohort	Knowledge: exam scores	Student performance on exams improved significantly in the module in which TBL was implemented compared to the didactic lecture groups one and two years prior (75% vs. 58% and 47%, respectively, p = 0.03).	“Performance of the students on the summative tests was improved in students who took TBL relative to those in previous classes, who were taught in a more traditional manner.”	The method of TBL used was modified; TBL was only implemented in two sessions; and the study did not compare with PBL or CBGD.
(Zingone et al. 2010)	Concurrent cohort	Knowledge: final grades Learner reaction	Students in the TBL group scored a significantly higher average GPA than the mixed active learning (MAL) group (3.7/4 vs. 3.3/4, p < 0.001). After adjusting for GPA prior to course entry, the authors determined the TBL group had earned an average 0.33 GPA points higher than the MAL group. Learner reaction was similar in both groups, though improved confidence was rated slightly, but insignificantly, lower in the TBL group (3.4/4 vs. 3.5/4, p = 0.900).	“Student performance, measured by quality points, was significantly higher in the team-based learning course format when adjusted for incoming GPAs. Students were satisfied with both learning models.”	Some students perform more favourably on different types of assessments; the content covered in each course varied slightly.

Table 8.  Methodological quality of randomised controlled trials (RCTs) using the Cochrane Collaboration's tool for assessing risk of bias

			Blinding
Author (Year)	Sequence generation	Allocation concealment	Participants*	Outcome assessment*	Incomplete outcome data*	Selective outcome reporting	Other
Koles et al. (2005)	Low	High	High	High	Low	Low	Low
Thomas & Bowen (2011)	High	High	High	High	Low	Low	Low
Willett et al. (2011)	High	High	High	High	Low	Low	Unclear

*Domains for which assessments are made by outcome were assessed for objective outcomes.

Figure 1. Flow diagram of included studies.

Table 9.  Methodological quality of prospective cohort studies (PCS) and retrospective cohort studies (RCS) using Newcastle–Ottawa Quality Assessment Scale

					Comparability of cohorts (Study controls)
Author (Year)	Representativeness of exposed cohort	Selection of non-exposed cohort	Ascertainment of exposure	Outcome of interest not present at start of study	Known factors	Additional factor	Assessment of outcome	Follow up long enough for outcomes to occur	Adequacy of cohort follow-up	Total stars (quality rating)
Conway et al. (2010)	Truly representative	Same community as exposed cohort	Secure record	No	No	No	Record linkage	Yes	Subjects lost unlikely to introduce bias	7 (good)
Koles et al. (2010)	Somewhat representative	Same community as exposed cohort	Secure record	No	No	No	Record linkage	Yes	Subjects lost unlikely to introduce bias	6 (fair)
Letassy et al. (2008)	Truly representative	Same community as exposed cohort	Secure record	No	No	No	Record linkage	Yes	No statement	5 (fair)
Levine et al. (2004)	Truly representative	Same community as exposed cohort	Secure record	No	No	No	Record linkage	Yes	Complete follow up	6 (fair)
Mennenga (2010)	Truly representative	Same community as exposed cohort	Secure record	No	Yes	Yes	Record linkage	Yes	Complete follow up	8 (good)
Nieder et al. (2005)	Truly representative	Same community as exposed cohort	Secure record	No	No	No	Record linkage	Yes	Subjects lost unlikely to introduce bias	6 (fair)
Pileggi & O’Neill (2008)	Truly representative	Same community as exposed cohort	Secure record	Yes	No	No	Record linkage	Yes	No statement	6 (fair)
Torralba et al. (2009)	Self-selected group	Same community as exposed cohort	Secure record	No	No	No	Record linkage	Yes	No statement	4 (fair)
Wiener et al. (2009)	Self-selected group	Same community as exposed cohort	Secure record	No	No	No	Record linkage	Yes	Loss to follow up >10%	4 (fair)
Zgheib et al. (2010)	Truly representative	Same community as exposed cohort	Secure record	No	No	No	Record linkage	Yes	Subjects lost unlikely to introduce bias	6 (fair)
Zingone et al. (2010)	Truly representative	Same community as exposed cohort	Secure record	No	No	Yes	Record linkage	Yes	Subjects lost unlikely to introduce bias	7 (good)

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