Creating an Effective Feedback Environment to Enhance Students’ Field Experiences

by Clare Olin, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Many students in higher education learn through field experiences, like internships or clinical “rotations.” During these experiences, an assigned preceptor helps the student to gain “on the job” experience to better understand their chosen profession. Experimental education is important because it provides students with an opportunity to use skills they initially learning about during didactic instruction. The preceptor reinforces the knowledge the student initially gained in the classroom.  Students also receive feedback from the preceptor who evaluates their performance.  Ultimately, these experiences and the feedback from their preceptors prepare them for their career. 

Feedback given by preceptors is meaningful in guiding a student’s growth. It’s important to create what Steelman and colleagues an effective “feedback environment.”¹ This is how feedback is delivered in both words and actions. Learners are more likely to accept and act on feedback when it is given well. There are seven variables that contribute to the feedback environment and influence whether the recipient will perceive the feedback as useful:¹

• Source credibility
• Feedback quality
• Feedback delivery
• Frequency of favorable feedback
• Frequency of unfavorable feedback
• Source availability  

Source credibility refers to how students perceive their preceptors. Students are more likely to acknowledge and implement the comments provided by people they highly respect.  Thus, a preceptor should be, first and foremost, a good professional role model.  Feedback is considered high quality when it is consistent, relevant, specific, and useful to the learner. Feedback delivery refers to both verbal and non-verbal communication. The reception of both positive and negative comments can be influenced by the tone, volume, word inflection, eye contact, and even body language of the deliverer. The frequency of favorable feedback can influence a student’s behavior and keep them motivated. Thus, positive reinforcement techniques can help engage students throughout their practice experiences and build positive attitudes and relationships. Positive feedback also builds students confidence and helps them develop independence. The frequency of unfavorable feedback is also important.  Constructive feedback is intended to help students improve and, when delivered effectively, can also keep students motivated. When unfavorable feedback is given, it is more likely to be taken positively if preceptors describe specific ways that the students’ performance can improve. Source availability refers to the how accessible the preceptor is – both physically and psychologically. Students are more likely to approach an accessible preceptor with questions and concerns. This can then help build a relationship between the two, and in turn, it may allow the feedback received to be more meaningful. While these seven principles were determined by observing employee relationships with their direct supervisors, the concepts are equally applicable to clinical instruction. In clinical teaching environments, students are preparing for a job and feedback strategies should be similar.² 

One study looked at the feedback strategies of preceptors in relation to student’s perceived feedback value.³ Students (n=132) from multiple states and with a variety of clinical experiences were asked to complete a survey. The survey consisted of three sections: demographic data, feedback environment scale (FES), and the feedback orientation scale (FOS).  The students were asked to rank statements about FES and FOS using a 5-point scale.  The FES section of the survey examined the following aspects of the environment:

• Source credibility
• Feedback quality
• Feedback delivery
• Favorable feedback
• Unfavorable feedback
• Source availability
• Promotes feedback-seeking behaviors

The FES represented how well students respond to the feedback “environment” that the preceptor created. The FOS included the student’s self-reflection on how they best use feedback and included:

• Utility
• Accountability
• Social awareness
• Feedback self-efficacy

The results demonstrated a significant positive correlation between the FOS and FES scores (p = 0.01), meaning that as the student’s perception of the feedback environment improved so did the perceived usefulness of the feedback given. When focusing on each element of the feedback environment, feedback utility was most affected by feedback quality and delivery. There was a significant relationship between accountability and the frequency of favorable feedback (p = 0.05), suggesting that consistency of feedback promotes the application of the preceptor’s assessments to the student’s daily work. Although utility, social awareness, and self-efficacy did not achieve statistical significance, there were positive relationships between each and the FES scores.

In order to implement these principles in practice, preceptors should start by being accessible and available to students. This should include providing phone number(s), email address, and reliable office hours or meeting times.  In addition, it is important to create a psychologically safe environment so that students feel comfortable reaching out. Regularly scheduled times for feedback can help the preceptor and the student stay on track. Preceptors should plan what to say in advance of these meetings and be prepared to give specific examples of both positive and negative observations.⁴ Preceptors should also encourage students to engage in self-reflection by using open-ended questions.  Finally, preceptors should give feedback promptly after a practice experience while the student can recall specific details.⁴

Keeping the seven dimensions of an effective feedback environment in mind can help new preceptors create positive field experiences. Constructive feedback should be specific and provide actionable strategies the student can use to improve their performance. Positive reinforcement should be given whenever a student has shown improvement. Effective feedback enhances students’ confidence and will enhance their ability to their professional responsibilities in the future.

References

1. Steelman LA, Levy PE, Snell AF. The feedback environment scale: construct definition, measurement, and validation. Educ Psychol Meas. 2004;64(1):165-184. doi:10.1177/0013164403258440.
2. Jonsson A. Facilitating productive use of feedback in higher education. Active Learn High Educ. 2013;14(1):63-76. doi:10.1177/1469787412467125.
3. Nolan T, Loubier C. Relating Instructor Feedback and Student Reception in the Clinical Environment. Radiol Technol. 2018 Jan;89(3):238-256.
4. Hardavella G, Aamli-Gaagnat A, Saad N, et al. How to give and receive feedback effectively. Breathe 2017; 13: 327–333.

Situational Judgment Tests (SJTs) to Measure Beyond Recall

by Karmen McMinn, PGY1 Pharmacy Community Practice Resident, Mississippi State Department of Health

In order to become a pharmacist, a student must receive a Doctor of Pharmacy degree. This means that they receive several years of education, but does all of that knowledge mean they will be successful? In addition to having a wide range of factual knowledge, pharmacists must also be able to display empathy towards patients and caregivers, work well in teams, and many other qualities that do not rely on the recall of facts.^1,2 These qualities (empathy, team player, etc) are sometimes be referred to as “soft” skills while being able to recall factual knowledge is often referred to as academic or cognitive skills.³ Some have argued that strong academic skills are inversely related to soft skills.^1,2 Thus, someone who earned straight A’s in those early science classes may struggle during advanced practice experiences.

One common requirement for pharmacy school admission is the Pharmacy College Admission Test (PCAT). The PCAT was designed to measure general academic ability and scientific knowledge. This background knowledge is something all students must have in order to be successful in pharmacy school. The problem with a test like this is that it only looks at a student's general academic knowledge while neglecting to assess other important skills a successful pharmacist must possess. For example, the PCAT does not assess a person’s ethical decision-making ability. This is where situational judgment tests (SJTs) might be useful. They can be an effective tool for assessing soft skills.^2,4

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SJTs are a type of psychometric test in which learners are presented with a realistic scenario or situation. Examinees are then presented with 4 or more actions they could take and instructed to pick the option they believe is the most appropriate – an action they would take in real life. The test taker is often asked to pick not only the most appropriate response but also the least appropriate response. In some SJTs, they are asked to rank the relative appropriateness of the responses from most appropriate to least appropriate.⁵ SJTs can measure traits not related to a person’s ability to recall factual knowledge.⁶ This can be done by making sure questions ask what the person “would do” instead of what someone “should do.”⁷ Skills that can be measured on an SJT include personality traits like conflict management, interpersonal skills, teamwork, and cultural awareness.^3,5 All of these skills can help identify people who would make amazing pharmacists that have the ability to interact with a wide range of people and work effectively as a part of a healthcare team.¹

In one study, investigators at Monash University in Australia developed an SJT. They used experts to evaluate the tool’s validity, reliability, fairness, and to determine the appropriateness of using an SJT as a formative assessment. This study appears to be the first to report on the development, implementation, and evaluation of SJT as a formative assessment for pharmacy students. They developed the test to help identify students that might need more training to develop the soft skills integral to becoming a successful pharmacist.³

Here is an example SJT scenario and directions³

Scenario
Nikhil, a pharmacy student, is working in a community pharmacy. A customer explains to Nikhil that she came to the pharmacy yesterday to collect some blood pressure tablets. However, when she arrived home, she realized that she had been given double the strength of the tablet that she required and has not taken any of the new medications. Nikhil arranges for the pharmacist to correct the medication and apologizes to the customer for the error. However, the customer looks angry and says, “sorry is not good enough.”

Response Instructions
How appropriate are each of the following responses by Nikhil in this situation?

Options: 
1 = a very appropriate thing to do; 2 = appropriate, but not ideal; 3 = inappropriate, but not awful; 4 = a very inappropriate thing to do

Responses

Inform the customer that he has already apologized to her and that there is nothing more that he can do

1. Tell the customer that he was not working yesterday
2. Tell the customer that she needs to calm down
3. Ask the customer whether she would like compensation
4. Ask the pharmacist to come and speak to the customer
5. Provide the customer with information on the pharmacy’s formal complaints procedure

The potential advantages of using SJTs in health professional curricula include building a student’s understanding of the concept “best” and “better” ways of performance and increases self-assessment skills. Self-assessment skills are an important part of continuing professional development. Providing students with feedback and the opportunity for reflection can help motivate further development of these soft skills. It can also be helpful to students by administering multiple SJTs so that they can see their improvement over time.^3,6

There are a few issues that educators should consider before implementing SJTs. First, it is important to make sure the scenario or situation is well described. There must be enough information for a student to be able to fully visualize the scenario. If a student cannot envision the scenario, it will be difficult for them to pick the “best” answer. Secondly, it is best to develop a scenario that does not force a student to choose an action that would go violate their personal beliefs and values.^3,7

Educators can use SJTs to help develop skills and traits, such as interprofessional skills and cultural sensitivity, that help students become better pharmacists. These tests can be used as a tool to assist with admission decisions but also deployed repeatedly throughout the curriculum in order to document change over time. By using SJTs for formative purposes, an institution can personalize the development of soft skills, focusing the student’s attention on weaknesses as well as uncovering strengths. In the end, every school wants to graduate well-rounded and well-educated pharmacists.^1,3


References:

1. Gilchrist A. Top 5 Pharmacist Personality Traits. Pharmacy Times. 2015 July 23.
2. Jones J, Krass I, Holder GM, Robinson RA. Selecting pharmacy students with appropriate communication skills. [Internet]. Am J Pharm Educ 2000; 64(1): 68-73.
3. Patterson F, Galbraith K, Flaxman C, Kirkpatrick CMJ. Evaluation of A Situational Judgement Test to Develop Non-Academic Skills in Pharmacy Students. Am J Pharm Educ 2019 [Ahead of Print]
4. About the PCAT. [Internet]. Pearson. 2019. Cited 2019 Nov 12.
5. Situational Judgement Test [Internet]. Psychometric Tests. 2019 Jan 9. [cited 2019 Nov 11].
6. Austin Z, Gregory PAM. Evaluating the accuracy of pharmacy students’ self-assessment skills. Am J Pharm Educ. 2007;71(5): Article 89.
7. Assessment & Selection. Other Assessment Methods. Situational Judgment Tests. United States Office of Personnel Management. 2019. Cited 2019 Nov 21.

Creating Meaningful International Pharmacy Experiences

by Katherine Baker, Pharm.D., PGY1 Pharmacy Practice Resident, North Mississippi Medical Center

International pharmacy experiences are increasingly popular. Today, students are eager to see the world and compare their learning environments to those of other students around the globe. In 2010, a survey of 114 pharmacy schools in the United States revealed that 40 had an active global/international program.¹ Having completed a global pharmacy experience during pharmacy school, I can speak to their value. I was fortunate to spend 5 weeks in Phitsanulok, Thailand at Naresuan University teaching hospital. What seemed like a distant dream soon became a reality when I found myself in rural Thailand with one of my best pharmacy school friends relying on the Google translator application to help us communicate. While international experiences have important benefits simply from “being there,” it is equally important to know how to design these experiences to maximize learning.

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First, it important to ensure that international experiences foster the development of the competencies required for graduation. Second, that there should be policies in place to ensure that the international site and faculty are qualified.² To address these requirements and the increasing demand for global health experiences, several initiatives have sought to improve the quality of international pharmacy rotations. Indeed, the American Association of Colleges of Pharmacy developed a special interest group that includes a dedicated team of individuals who discuss topics and ideas related to global healthcare.¹  

Prior to establishing an international experience and sending student pharmacists across the globe, great attention should be paid to ensuring that both the student and the host site are prepared for the visit. The planning period for my international rotation was stressful due to unknowns that come with living and learning in a foreign country. These stresses were alleviated when the host site sent me documents with helpful information about our living arrangements and coordinated everything before arrival. A number of articles have explored important considerations that must be taken into account before developing a Global/International Advanced Pharmacy Practice Experience (G/I APPE). These considerations include host country, home institution, host institution, faculty/preceptors, and student issues.² 

The host country is an important factor to consider before establishing an international rotation. While having a well-thought-out curriculum is necessary, ensuring a safe and functional learning environment in a foreign country is even more important. Pharmacy schools need to ensure that students are well informed about the country they will be traveling to.  Students should try to learn about the local culture(s) and basic parts of the native language. This will help them while navigating abroad as well as improving patient interactions during the experience. While in Thailand, I worked in an anticoagulation clinic and was asked to interview and counsel patients. I struggled to communicate and had to rely on my preceptor. This particular experience would have been much more meaningful had I learned the language ahead of time. Logistics of the rotation such as visas, living arrangements, transportation, and financial considerations should also be addressed well in advance. 

Equally important are the host institution and the curriculum. To justify an international experience, the host institution should be vetted and deemed an appropriate pharmacy experience. It is recommended that the host and home institutions have a designate representative. These designated faculty members will be responsible for communicating student educational needs, learning outcomes, and detecting any red flags.¹  In addition, a thorough and thoughtful syllabus must be drafted and approved. Just like any other course or experience in pharmacy school, the syllabus should lay out expectations, goals, objectives, and grading criteria.¹    

Student interaction while on rotation is another important consideration to create a meaningful experience abroad. For students to take full advantage of their international pharmacy experience, they should be meaningfully engaged and aware of what they are learning. One descriptive study discusses the importance of reflective writing while on rotation. Based on student reflections, the authors noted a pattern to student learning while on a G/I APPE. Students use “communication, problem-solving, and adaptability”³ skills while on rotation and then reflect on the major differences between their home and host country. There a couple of ways to get students to reflect about their experiences.  One method is to ask students to keep a personal journal and regularly writing entries.  Another way to encourage reflection is to require students to give a presentation to peers after completing the experience. My pharmacy school required each student to create a weekly travel blog reflecting on their experiences (check out our blog: Thailand Adventures - Two Pharmacy Students Finding Their Way Through Thailand). This exercise helped us to reflect and translate what we learned abroad and apply it to our lives in the United States. Our blog essays were also useful to future participants. Indeed, many of our weekend excursions were based on blog posts from previous students!

Global pharmacy experiences are not only an adventurous, once-in-a-lifetime experience, they also enhance a pharmacy student’s professional advancement. In a world that is becoming smaller and more connected through technology, a G/I APPE will give students an opportunity to grow their perspective and sensitivity towards people from other cultures.¹ Students who have participated in a global pharmacy rotation are more likely to be culturally aware and “demonstrate increased interest in volunteerism, humanitarianism, and public health.”² Moreover, international experiences often help students improve their communication skills, problem-solving skills, and adaptability.³  

Having participated in an international rotation myself, I can attest to many of these benefits. If I could give any piece of advice, I would encourage students heading into an international experience to learn some of the host country’s language and keep a travel journal or blog. It’s also important to give both the host and home sites feedback. The home institution often go to great lengths to ensure that the rotation will be maximally beneficial but the best information is feedback based on personal experience. The host institution that I completed my rotation at required students to complete an in-depth exit survey. The institution wanted an honest review of the experience and it was important to openly discuss any concerns to better serve students for the future.

International pharmacy experiences are a once-in-a-lifetime opportunity that I would recommend to all pharmacy students. If the experience is well planned and executed by both the host and home institutions and if the student approaches the experience with enthusiasm and an open mind, it will be a personal and professional growth experience the student will never forget.

References:

1. Steeb DR, Overman RA, Sleath BL, Joyner PU. Global Experiential and Didactic Education Opportunities at US Colleges and Schools of Pharmacy. Am J Pharm Educ. 2016;80(1): Article 7. doi:10.5688/ajpe8017
2. Alsharif NZ, Dakkuri A, Abrons JP, et al. Current Practices in Global/International Advanced Pharmacy Practice Experiences: Home/Host Country or Site/Institution Considerations. Am J Pharm Educ. 2016;80(3): Article 38. doi:10.5688/ajpe80338.
3. Steeb DR, Miller ML, Schellhase EM, et al. Assessment of Global Health Learning Outcomes on International Experiences. Am J Pharm Educ. 2019. doi: 10.5688/apje7586

Is There a Perfect Late Work Policy?

by Kaitlyn Dupuis, PharmD, PGY-1 Pharmacy Resident, North Mississippi Medical Center, Tupelo, MS

When it comes to teaching, there are several logistical issues that people often overlook — like dealing with students who do not turn-in assignments on time.  When assignments are submitted late, it often creates additional work for the teacher and inequities with other students who did not have the benefit of extra time.  It’s difficult to develop a completely fair and consistent “late work policy.”  Some teachers choose to accept late work within a few days of the assignment’s due date for full credit.  While others will accept late work with points deducted. And still others do not accept late work at all.  Some teachers believe that if the work is assigned, it is important to the student’s education. Therefore, they accept late work to encourage students to complete all assignments.

The majority of teachers understand that there are certain circumstances when students simply can’t finish their assignment by the due date.  Sometimes things pop-up in life that nobody has control over.  While some excuses are valid, there are times when students lie or use excuses that really did not prevent them from submitting their assignment on time.  It’s very difficult to determine which excuses are valid and which excuses just don’t “add-up.”   While teachers want to be compassionate and understanding, it is also in their job description to prepare students for the future in a world where deadlines matter and there are consequences.

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In a recent article posted on the Faculty Focus website entitled A Headache-Free Late Work Policy by Dr. Laura Schisler, the author proposes a “make-up day.”¹ The “make-up day” allows for students to turn-in they missed assignments throughout the semester on the make-up day to receive partial or full credit.  This removes the need to determine the validity of each student’s excuse.  This provides everyone the same opportunity to submit missed assignments, no matter the reason.  This policy makes it harder to miss multiple assignments, because students must turned-in all assignments on the predetermined make-up day at the end of the semester. The student either has to complete the assignment near the initial due date and hold-on to it until the end of the semester or complete the assignment at the end of the semester when there is typically an overwhelming number of tests and assignments.

In her essay entitled It’s Time to Ditch Our Deadlines, Dr. Ellen Boucher writes about her experience with a rigid late work policy.²  She states that early in her career students would lose one-third of their grade for an assignment for every day that passed without turning in the work.  In her experience, because the consequences were so severe, students were turning in work just to say that they were turning it in.  Other students would not submit anything and simply disappear because there was no way to pass the class.  Dr. Boucher began to realize that anxiety and burnout were a problem, so she then adopted a policy where students could submit their assignments two-days late for full credit.  Even after the two-day grace period, she would allow the student to meet with her to discuss a plan to turn-in the assignment.  Dr. Boucher saw that her students were working diligently to turn-in quality assignments rather than turning-in assignments simply for completion.  Dr. Boucher saw the level of anxiety and burnout decrease and felt this compassionate approach benefited her students. While it is true that anxiety and burnout are on the rise among students in both college and high school, allowing students to freely turn assignments in, beyond the deadline, can teach students bad habits.^3,4

While researching late work policies, I came across a few articles regarding “No zero policies.”  There are several schools that are transitioning to policies that don’t allow grades lower than 50%.  If the student refuses to turn-in his or her assignment, they still receive a 50%.  The philosophy behind this approach is that a zero is simply impossible to “bounce back” from.  One zero in a semester can cause a student to fail the entire class.  People in favor of the “no zero policy” argue that punishing the student with a zero is not actually assessing their knowledge.  While some people are very much in favor of a no zero policy, some people think it’s ridiculous.  The article cites a Facebook Post called “Is Our Grading System Fair” that asked 300 members Edutopian Innovative Teachers of English to comment.  Many people disagreed with the policy, simply because it requires students to do very minimal work in order to pass a class.³ 

I think that late work policies should vary, depending on the student age and nature of the course.  When teaching elementary school kids, late work policies should be more lenient.  Children in lower grade levels do not have control of their home life and aren’t always responsible enough to get their school work done without parental guidance.  I believe that it is appropriate for teachers to allow students to turn-in late work with minimal consequences when they are in lower grade levels.  As students age, they should become more responsible and should know that school is a priority. While life can still get in the way of older students, I believe that there should be consequences for late work the majority of the time.  Of course, there should be exceptions for unforeseeable life events, like an serious illness or death in the family, but students must learn that there are consequences in life when things aren’t done by their deadline. College professors should have a more stringent late work policy.  I know that burnout and anxiety are very real, but deadlines are deadlines and the consequences should be bad enough to create strong incentives to turn assignments in on time.  Indeed, a study done at Illinois Wesleyan University actually showed that students think that late work penalties are fair.⁵

There probably is no perfect “late work policy.”  I believe that there are times that deadlines should be extended — so I disagree with “zero tolerance policies.”  I also believe that students should meet deadlines.  While I agree that teachers should be compassionate and understanding, I also believe that they are doing students an injustice by allowing them a two-day grace period on every assignment or by giving them 50% even if they fail to submit anything.  I really like having a “make-up day” at the end of the semester.  This allows for students to still receive credit for missed assignments but doesn’t require the teacher to create a policy about "acceptable excuses" for late work.  The “make-up day” is usually during a very busy and stressful point in the semester which should encourage students to turn in their work by the due date.  The major drawback to a “make-up day” is that it signals to students that it’s “ok” to not meet deadlines.  Important life skills are learned in school and one is time-management.  If you fail to meet deadlines in life, you will find yourself without a job … and maybe without electricity.

References:

1. Schisler L. A Headache-Free Late Work Policy. Faculty Focus. Faculty Focus - Higher Ed Teaching & Learning. August 22, 2019.
2. Boucher E. It's Time to Ditch Our Deadlines. ChronicleVitae for higher ed jobs, career tools and advice. September 2, 2016.
3. Minero E. Do No-Zero Policies Help or Hurt Students? Edutopia. https://www.edutopia.org/article/do-no-zero-policies-help-or-hurt-students. July 3, 2018.
4.  Center for Collegiate Mental Health. 2018 Annual Report (Publication No. STA 19-180).
5. Lui M and Nillas L. Late Work Policies: Their Impact on Student Achievement. John Wesley Powell Student Research Conference, 2015. Abstract 8.

Team-based Learning (TBL) in the Health Professions

by Mallory Pullman, PGY1 Pharmacy Practice Resident, The University of Mississippi Medical Center 

Today, to meet the current healthcare needs of society, health professions students must be able to learn vast amounts of information and have a deep understanding of difficult concepts. In addition to having a comprehensive knowledge base, health professions students must be able to apply this knowledge to varying clinical scenarios.  Further, they must be able to work both independently and in collaboration with others. It is therefore necessary that teaching approaches in health professions education be tailored to these needs, preparing students for their careers. 

One method of learning that is starting to gain traction within health professions education is team-based learning (TBL). TBL is an instructional method that emphasizes self-preparation outside of class followed by the application of the knowledge learned in class. In TBL, courses are typically separated into modules or units and students are assigned to small groups. Before class, students are given materials to review, which they must learn independently. Assigning materials to review prior to class ensures students are responsible for their own understanding and gives students the opportunity to learn the material in a way that is most effective for them.

Then, at the start of each class, students are given an assessment to analyze how well they have learned the material. The assessment is termed an individual Readiness Assurance Test (IRAT).  Students first complete the test as an individual and, then, as a team – an assessment called the group Readiness Assurance Test (GRAT). Both the individual and group scores contribute to students’ grades. After the students complete the team test, they have the opportunity to discuss the material with the instructor and appeal answers they got incorrect. The discussion and appeal process enhances students’ understanding by requiring students to defend their answers. Students also learn by listening to the rationales provided by other teams, providing students with diverse perspectives. To conclude the assessment portion of each class, the instructor may present a brief lecture and lead a discussion on concepts students appear to be struggling with most. To further reinforce students’ learning, the remainder of each class is focused on completing application exercises.¹ 

Before deciding to implement TBL, it is crucial to examine how effective the learning method is, especially in health professions education. Constructivist learning theory, whereby the student “constructs” his/her own knowledge, provides the theoretical basis for TBL. TBL places the responsibility of learning on students by requiring them to be prepared for assessments at the start of each class and be ready to use their new knowledge to solve relevant problems.²  Several studies have shown TBL improves learning. One study assessed the impact of TBL on academic performance during comprehensive course examinations for second-year medical students.³ In a 2-year analysis of 178 second-year medical students, analyzing scores on 28 comprehensive course examinations, the investigators found that grades increased by a mean of 5.9% after TBL implementation, with lower-achieving students reaping a greater benefit.³ The authors concluded that the application exercises, allowing teams to use their aggregated knowledge to solve challenges, and the interaction with peers and faculty, likely contributed to the positive impact on students’ learning.

Similarly, a study conducted by Zgheib and colleagues examined the effect of TBL on learning in a second-year medical pharmacology course.⁴ The researchers evaluated individual and group answers to all IRAT and GRATs, concluding that TBL approaches were more effective than traditional learning methods. While TBL appeared to improve student understanding of difficult concepts, the authors felt the method was not more effective for learning simpler concepts.

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Another advantage of implementing TBL, especially in health professions education, is the opportunity to acclimate students to working in teams. In the health professions, it is common for physicians, pharmacists, nurses, and other medical professions to work closely together to solve complex medical problems. Using TBL methods in the classroom, where students practice listening to one another and sharing knowledge to solve challenges can prepare students for collaborating with health profession colleagues throughout their careers. Overall, TBL not only improves academic performance and students’ understanding of difficult concepts, it gives students an opportunity to practice the team-work skills they will need throughout their careers.

The potential advantages of the TBL method provide enough justification for health profession educators and programs to implement this learning technique. Health professions educators can implement TBL techniques by simply requiring students to self-prepare outside of class and reserving class time for group interaction.  To hold student accountable for pre-class work, it is important to use reinforcement examinations. This pre-class work is critical for the discussions and application exercises to be successful.

However, there are a few logistical issues that educators should consider before implementing TBL in their courses. First, educators must consider how they will form student teams. In order to develop group cohesion, TBL groups should remain the same throughout the duration of the course. Ideally, teams should be strategically formed based on three principles: 1) teams should be assigned by the instructor - not student-selected; 2) teams should be as diverse as possible; and 3) the selection process should be transparent.⁵ Implementing these principles allows the development of diverse groups that bring different strengths and experiences to the discussion and application exercises. In addition to discussing how team assignments were made, educators must orient students to the TBL method by explaining pre-class preparation, application exercises, and the readiness tests. Ensuring that students have a complete understanding of TBL and its benefits is essential for students and co-instructors.  Getting everyone’s commitment is critical when implementing a novel teaching approach. Using the principles of instructional design, considering the design, development, and implementation of each instructional unit, are fundamental to the success of TBL. 

References:

1. What is TBL?. Team Based Learning Collaborative. Published 2019. Accessed October 23, 2019.
2. Brame C. Team-based learning. Vanderbilt University. Published 2019. Accessed October 23, 2019.
3. Koles, P. et al. The Impact of Team-Based Learning on Medical Students’ Academic Performance. Academic Medicine 2010;85(11): 1739-45.
4. Zgheib N. et al. Using team-based learning to teach pharmacology to second-year medical students improves student performance. Medical Teacher 2010;32(2):130-5. 
5. Getting Started with TBL. Team Based Learning Collaborative. Published 2019. Accessed October 24, 2019.