Building Authentic, Meaningful, and High-Quality Team-Based Learning Activities

by Megan Harlow, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

In pharmacy school I participated in many team-based learning activities. As an introvert, I found it challenging to be thrown into a (seemingly) random group and try to work toward a common goal with people who may not care about the end result as much as I did. None-the-less, some team-based learning activities were satisfying learning experiences and I actually had fun working with others applying our knowledge to a (seemingly) real-life situation. Some of these experiences are by far my favorites in pharmacy school.

Team-based learning is a type of small-group learning that requires student preparation prior to class and devotes class time to application exercises. Before class starts, students complete a pre-class activity (reading, watching videos, etc.) to learn about the key concepts that will be needed during the in-class activity.¹ The class starts with each student taking a test to assess his/her readiness after which the same test is completed by students as a team. At some point, either during or after the group readiness test, the instructor reveals the answers. Depending on the testing procedures employed by the instructor, the groups may find out if their answers are correct during the testing process. For example, one of my classes used scratch-off answer cards. The correct answer had a star next to it to indicate that the answer was correct. Computer methods for scoring the group readiness test can also be used. Students have the opportunity to appeal the correctness of any answers with which they disagree. After the testing is finished, a short presentation may be given whereby the instructor hones in on concepts students struggled with on the test.

Image from: Sultan Qaboos University medical journal 12(3):336-43

After the readiness testing, students then work in small groups on application activities.  These activities present the student groups with a problem for which they are require to select a specific course of action.¹ All teams report their decisions at the same time.  This gives the students an opportunity to see how other teams have managed the problem differently. The teacher does not tell students the answer but rather guides the teams as they work through the problem toward their own solution.¹ The theoretical basis of this instructional method is grounded in constructivist learning theory, whereby the active involvement of the student is essential to the process. Students are encouraged to use their life experiences and knowledge while trying to solve the assigned problem.^1,2

While this instructional strategy sounds great, things don’t always live up to the ideal. Yes, when the activities are well-designed, students have the opportunity to acquire foundation knowledge and they get to apply those concepts to problems. Students are also learning how to work with others who may have different backgrounds and opinions from their own. However, some team-based learning activities aren’t well-designed and students don’t achieve the desired learning outcomes. This was a problem I faced several times during my undergraduate and pharmacy school years. Learning activities that are not well-designed lead to frustration among students and can cause group tension. One of the hardest parts of creating team-based learning activities is developing assignments that encourage deep thinking as well as engaged, content-focused small group discussion. The problems that the groups attempt to solve should be authentic and have clear application to their future roles.²

So, what makes a team-based learning activity effective? A recent study solicited the opinions of pharmacy educators who are experts on team-based learning to identify quality indicators for team-based learning activities. A two-rounded modified Delphi process was used whereby these experts were asked about the characteristics of strong team-based learning activities and how to create positive learning outcomes as well as enhance student satisfaction.² The first round of the Delphi process asked the experts a series of open-ended questions about team-based learning activities. These thoughts and opinions were then summarized and a series of best practice statements were formulated.  The investigators presented these statements back to the experts to measure their level of agreement.²

According to the expert panel, effective team-based learning activities must be focused and clear instructions must be provided to students.  Students should know what they are being asked to do and what they need to do to prepare for the in-class activity using the assigned pre-class background materials. The learning activity must be feasibly completed in the allotted in-class period but also appropriately challenging and complex. There also must be time allotted to providing effective feedback to each group. The content of the activity should be an authentic challenge in pharmacy practice and require the application of multiple domains of knowledge and/or skill.² The activity should encourage the group to pool their prior knowledge and life experiences together to solve a multifaceted problem. The activity should be clearly linked to an outcome or objective of the course but should also require students to apply their knowledge from other courses. In addition, a good team-based learning activity should prepare students for future assignments. Lastly, team-based activities should promote higher-level thinking, encourage group discussion, and require the involvement of every student in the group.²

Feedback is an essential component of team-based learning for both learning and long-term retention. Feedback should be included at each step of the process. The individual and group tests provide feedback on the students’ preparation for the activity. While working with their group, students receive peer feedback as well as feedback from the instructor on the group’s ability to prioritize, organize, and defend their approach to the problem.²

To illustrate these concepts, here’s a team-based activity I participated in during pharmacy school. The module was related to pain management. The syllabus provided explicit instructions on what should be done before coming to class. The class was assigned two presentations to review. We then took a quiz to assess our pre-class learning and the instructor gave a short lecture before beginning the team activity. The assignment was able to be feasibly completed in the class period and there were several facilitators to keep us on track. The subject matter included many new concepts for my classmates, so the problems were straight forward but challenging. We had access to evidence-based resources during the activity. During the assignment, each group was given feedback about their progress. We all understood how this activity was relevant to our future professional role as pharmacists and it required us to recall things we learned during pharmacotherapy courses earlier in the curriculum and apply them to a case. 

Some students may be resistant to this form of instruction at first. Over time student objections and concerns will likely subside. One study, which surveyed occupational therapy students about their perceptions of team-based learning, showed that students were significantly more satisfied with team-based instruction after the third trimester when compared to their opinions after the first trimester.  Moreover, students reported they were significantly more accountable for completing the pre-class assignments.³ These findings indicate that students need time to become accustomed to the team-based learning technique and must learn how to meaningfully engage in the in-class activity.

While team-based learning can promote higher-order thinking, problem-solving, and teamwork, these all depend on designing effective pre-class and in-class learning activities.  Students need clear instructions about what they need to do to prepare.  Feedback at each step of the process is important.  The instructional activities need to align with the course objectives.  And the in-class group activities should be relevant, sufficiently complex, but achievable in the allotted time.   By keeping these principles in mind, instructors can create authentic, meaningful, and high-quality team-based learning activities that have a lasting impact.

References

1. Brame C. Team-based learning. Vanderbilt University. 2020.
2. Janke K, Bechtol R, James S. Determining indicators of high-quality application activities for team-based learning. Am J Pharm Educ 2019;89(9): Article 7109. 
3. Carson R, Mennenga H. Team-based learning and the team-based learning student assessment instrument (TBL-SAI): a longitudinal study of master of occupational therapy students’ changing perceptions. Am J Occupational Ther 2019;73(4): 7304205010p1–7304205010p7.

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.