Using Team-Based Learning in Teaching Undergraduate Pathophysiology for Nurses

Abstract

This paper describes the development, implementation and evaluation of Team-Based Learning (TBL) in a third year undergraduate nursing module.

Keywords:

• biosciences
• team-based learning
• pathophysiology
• nursing

Introduction

A key challenge for nurse educators in Higher Education Institutions (HEIs) is judicious selection of teaching and learning strategies which enable students to analyse, integrate and apply a range of knowledge types that inform the clinical decision-making required to deliver competent and compassionate nursing care in the workplace. Alongside the achievement of Nursing Midwifery Council standards for education (NMC 2010), student nurses must also achieve a range of graduate skills. Critical thinking and teamwork are key desirable qualities for nurses to possess (March & McPherson 1996, Thomas et al. 2003, Shin et al. 2006).

One approach to this pedagogical challenge was developed by Michaelson and colleagues in the United States of America. Known as Team-Based Learning (TBL), it represents an approach to providing the learning opportunities available in small group tutorials, but via delivery in the context of large groups of up to 200 people. TBL is a tutor-directed method that incorporates multiple small groups within a single classroom. It aims to move “beyond basic acquisition of facts to emphasise application of content to real world scenarios” (Haidet et al. 2012, p293). It is particularly appropriate to the education of health professionals because it focuses on complex reasoning through problem solving, and fostering team working skills. In TBL, the face-to-face time spent with an instructor is an opportunity for students to practise application of concepts learnt outside the classroom setting. This is an example of the “flipped classroom” described by various educators (Lage et al. 2000, Cannod et al. 2007).

TBL has been implemented in a range of health-related disciplines. This includes undergraduate nursing (Mennenga & Smyer 2010, Anderson et al. 2011), optometry (Hrynchak & Batty 2012), pharmacy (Beatty et al. 2009, Addo-Atuah 2011, Ofstad & Brunner 2013) and medicine (Zgheib et al. 2010, Parmalee & Hudes 2012, Wilson-Delfosse 2012). In a review ten years after the introduction of TBL to ten US medical schools, a study by Thompson et al. (2007) found that nine schools continued to utilise TBL as the mainstay of their curriculum with widespread faculty and student satisfaction.

Method

TBL was introduced to a pre-existing module within the BSc Nursing programme. The module, entitled Pathophysiology Applied to Nursing Practice, is a level 6 module forming one of two 30-credit ‘top-up’ modules enabling students to achieve an undergraduate degree as opposed to the usual Advanced Diploma award. From an educational point of view this module was considered suitable to trial TBL, because it requires students to develop understanding of pathophysiological principles, as well as to integrate and apply this knowledge into their clinical decision-making and nursing practice. These requirements are particularly suited to the structured activities of TBL, with the ‘readiness assurance’ relating to the factual pathophysiology, and the application activities providing the context for application to nursing practice of the pathophysiology principles. As a year three module, it was anticipated that students would bring with them some clinical experience.

An equally important but practical consideration was that the module runs on eight consecutive fully timetabled days. This meant that all the TBL class activities could be completed within one day, and the learning outcomes for each study day did not require significant change. The small module team of four academics from the Division of Nursing who normally delivered the module was enthusiastic about trialling TBL. The make-up of the module team comprised two module leaders (a nurse with expertise in palliative and end of life care, and a biosciences lecturer with expertise in genetics and experience of nurse education). The remaining two module lecturers included a pharmacist and a diabetic nurse consultant. This mix of expertise facilitated the team-teaching approach adopted for most teaching sessions.

The learning outcomes centred on students demonstrating in-depth understanding of pathophysiology and pharmacology of a range of conditions as they relate to nursing practice. Biological principles covered included cell biology, genetics, cell division, cell injury, carcinogenesis and aspects of neurobiology. These were used to understand and provide a rationale for the nursing management of pain, depression, diabetes and cancer.

The module involved 21 students from the fields of nursing (adult, child and mental health). Three teams of seven were formed using random allocation. The students were prepared for TBL on the first day of the module by the module leaders explaining the principles and rationale for TBL. The students went away from the first day with instructions on the pre-reading.

The sessions were prepared by modifying pre-existing resources. The module was divided into four main topics: pain, depression, diabetes and cancer; each topic being given two full-days of teaching. Detailed learning outcomes were produced for each topic, and then further narrowed to produce learning outcomes for each of the eight sessions. Pre-reading material was identified covering all the learning outcomes of each session. The learning outcomes and the pre-reading in turn, guided the writing of ‘Readiness Assurance’ questions and the application activities (Box 1 and Figure 1).

Figure 1 Structure of team-based learning

Box 1 The Team-Based Learning method

Table

TBL consists of a three-step process: 1) pre-class preparation 2) ‘assurance of readiness’ and 3) application activities.

1. Pre-class preparation: Pre-reading and/or other activities (such as podcasts, lab results or policy document; see Figure 1) are given to the students one week in advance of the session. This material must cover the content necessary to answer the application exercises. This step provides the first opportunity for the students to engage independently with the module content. 2. Assurance of readiness   i. iRAT (individual Readiness Assurance Test) consists of between 10 to 25 multiple choice questions and constitutes the students first in-class activity.   ii. tRAT (team Readiness Assurance Test). The students join their pre-set team and as a team, must agree on the answers to the same multiple choice questions as made up the iRAT. The team gains immediate feedback through the use of scratch-cards (known as Immediate Feedback-Assessment Technique; IF-AT).   iii. Appeals. Students are able to challenge ambiguous answers.   iv. Mini-lecture. At this point the tutor may decide to summarise some of the key points or clear up any confusions the students have. 3. Application activities Teams discuss the same, relevant clinical problem, and make a specific choice from a number of options. An example is given below (Cancer 2a). Team responses are displayed simultaneously to the whole class, using pre-prepared cards labelled A to E. A discussion between the teams ensues facilitated by the tutor. Cancer 2a You discover that John is 42 and works for a haulage company which specialises in the distribution of agricultural chemicals. His diet while he is on the road includes soft drinks, crisps and sandwiches. He has a BMI of 32. He is prone to constipation. He delayed consulting his GP for several months as he initially thought the bleeding was due to piles and was embarrassed. His mother is alive and well and his father died 12 years ago of lung cancer. You are working on the day he receives his diagnosis (Stage 2 colorectal cancer). He calls you over and asks you how he got his cancer. Using what you know of the process of carcinogenesis, select which of the following best describes how John might have developed cancer:   A. Reduced intake of dietary fibre leads to exposure of epithelial cells of colon to toxins which may cause mutations in cells.   B. Inherited mutation in APC gene which leads to vulnerability to cancer.   C. The interaction of environmental factors such as diet, and genetic factors such as mutations in tumour suppressor genes.   D. Lack of physical exercise is a risk factor in developing colorectal cancer.   E. Exposure to agricultural chemicals in transit leads to damage to DNA and resulting mutations.   F. Sugary drinks lead to suppression of immunity, enabling cancer cells to go undetected by the cells of the immune system.   G. Mutations are a frequent event in normal cell division and usually damaged cells are repaired or destroyed, but due to probability there may be times this does not occur.

Seminar rooms with flexible seating and tables were used to facilitate easy movement between team and whole group discussion. The sessions were facilitated by one or two of the team, depending upon staff availability. The TBL method adopted is described in Box 1 and Figure 1.

Findings

The effectiveness of TBL was evaluated using a combination of observations of class dynamics, informal verbal feedback, and formal qualitative and quantitative module feedback forms.

Initial observations of student-engagement

The team scratch-card activity (see Box 1) seemed to be very popular with students. There was a high level of animation, with whoops and cheers when correct answers were identified, and groans when the responses were incorrect. When walking around the groups we were aware of some very clear and focused arguments as to why individuals had selected certain answers. We were also aware of an interesting dynamic which, whilst documented in the TBL literature, was not anticipated. The vocal students were not necessarily the most knowledgeable and, initially, several incorrect answers were selected by groups responding to the loudest voice. However, once these students had compromised their team’s score, they appeared over time to develop their pausing and listening skills. In contrast, those quiet students who felt they knew the answer but lacked the confidence to speak out were triggered into contributing once they observed their team’s incorrect answers. Over a period of several weeks a levelling effect was observed in the team dynamics, where the motivation for competition with other teams catalysed the gradual development of cohesive and effective team working. Students appeared to quickly realise that the way to justify their team choice of answer was not to simply base it on the most common response, but to demonstrate that they were using knowledge from the pre-reading to justify that none of the other options could be correct.

Discussions arising from the Application Exercise in Box 1 were interesting and varied. One student discussed that there are implications in selecting the answer based on patients’ personality and level of understanding, and that you might select an answer that is not necessarily the most accurate from a pathophysiology perspective because it is the most appropriate way to frame information for that patient at that time. Additionally, discussions took place relating to the positive and negative aspects of screening for common cancers, and the changing rules around health and safety at work that may minimise the occurrence of exposure to hazardous substances. All of these topics, whilst not directly related to the learning outcomes of the module, bore a clear relevance in terms of nursing practice, and show evidence of critical thinking.

Student feedback

In order to provide formative evaluation of Team-Based Learning to the module team, students were invited to complete a Likert-scale structured questionnaire where they ranked their level of agreement with a range of questions relating to the TBL learning experience. The most highly ranked statements were: “I found the discussion and debate stimulating and interesting” and “TBL helped me to think critically more than other methods of learning”. Verbal feedback was also obtained. The student group were unanimous in their positive feedback. Students reported that they usually “switch off halfway through” lectures and that TBL sessions were “interactive and gave the opportunity for discussion and see other students’ rationales”. It was observed that the technique enables lecturers to “try to bridge the gap and bring something realistic into the learning environment”. One student observed that “having to work in a different team helps prepare us better for having to maintain a professional working relationship even when we don’t like someone personally”.

Discussion: benefits and challenges

The benefits of using this teaching and learning strategy were clear early on. It enabled a single tutor from the team to effectively capture the attention and commitment of relatively large student groups. Attendance at sessions was excellent; where students were unable to attend they seemed to genuinely regret that they had missed out on the opportunity to join in the group discussions. Student enthusiasm was indicated from the amount of debate generated, as well as the quality of questions and discussion topics.

Preparation for the sessions was initially challenging. Appropriate individual Readiness Assurance Test (iRAT) Multiple Choice Questions (MCQs) require both clarity and complexity. If answers relied too much on factual recall they would not develop students’ critical thinking skills, as one either knows the answer or does not. If too ambiguous, the students would argue for extended periods of time without gaining a clear sense of the best answer. Over the duration of the module, developing MCQs became easier as it was evident which types of questions had generated the liveliest discussion. Following the team responses, the lecturers would facilitate a whole group discussion, avoiding providing answers, instead using questions such as: “Was there a close second choice?” and “Can you explain a little more of the thinking behind your choice?”. This was always interesting and students demonstrated a high level of engagement throughout. They also had the opportunity to listen to other teams’ rationales and perspectives.

The technique requires significant changes to the philosophy of teaching, the learning objectives, the nature of what happens within the classroom and the role played by the teacher. This style of facilitation may suit some educators more than others, and there may be training implications for widespread adoption of the technique. It is harder, though not impossible, for teams to function well in traditional tiered lecture theatres, necessitating some creative use of seating planning and the development of flexible necks! A dedicated TBL space is available, though not sufficiently large for the group size on the pre-registration nursing programme. Institutional investment may be required to develop appropriate learning areas, resources and activities. Another challenge related to students arriving late and missing the iRAT. Attendance improved over the course of the module, perhaps because students were motivated by the pressure exerted by the team, or the embarrassment of trying to answer the team Readiness Assurance Test (tRAT) questions without having first had time to think them through individually. The time required to identify appropriate pre-reading and develop the activities is undoubtedly greater than for lectures. Overall, the team perceived that this was offset by the fact that the teaching was much more enjoyable, interactive and participatory. Furthermore, there was no requirement for additional labour-intensive small group tutorials.

A key aspect of TBL relates to integrating summative assessment into the Readiness Assurance Tests and the Application Exercises. This has not yet been implemented in this university. Evidence strongly suggests that this further develops the positive team dynamic, and some educators have incorporated peer assessment into this process, where students rate one another’s contribution to the team activities, and their assessment grade is weighted according to their ranking in the team (Michaelson et al. 2002).

A paradigm shift in nursing education is overdue. Educators need to identify teaching and learning strategies that enhance and deepen student learning and engagement, developing their analytical skills and ability to integrate and apply the range of knowledge appropriately into their decision-making, assessment and management of patient care. Team-Based Learning presents a powerful tool for developing this aspect of education.