Journal of Midwifery & Women’s Health
www.jmwh.org
Original Research
Team-Based Learning for Midwifery Education Tonia L. Moore-Davis, CNM, MSN, Mavis N. Schorn, CNM, PhD, Michelle R. Collins, CNM, PhD, Julia Phillippi, CNM, PhD, Sharon Holley, CNM, DNP
CEU
Introduction: Many US health care and education stakeholder groups, recognizing the need to prepare learners for collaborative practice in complex care environments, have called for innovative approaches in health care education. Team-based learning is an educational method that relies on in-depth student preparation prior to class, individual and team knowledge assessment, and use of small-group learning to apply knowledge to complex scenarios. Although team-based learning has been studied as an approach to health care education, its application to midwifery education is not well described. Methods: A master’s-level, nurse-midwifery, didactic antepartum course was revised to a team-based learning format. Student grades, course evaluations, and aggregate American Midwifery Certification Board examination pass rates for 3 student cohorts participating in the team-based course were compared with 3 student cohorts receiving traditional, lecture-based instruction. Results: Students had mixed responses to the team-based learning format. Student evaluations improved when faculty added recorded lectures as part of student preclass preparation. Statistical comparisons were limited by variations across cohorts; however, student grades and certification examination pass rates did not change substantially after the course revision. Although initial course revision was time-consuming for faculty, subsequent iterations of the course required less effort. Discussion: Team-based learning provides students with more opportunity to interact during on-site classes and may spur application of knowledge into practice. However, it is difficult to assess the effect of the team-based learning approach with current measures. Further research is needed to determine the effects of team-based learning on communication and collaboration skills, as well as long-term performance in clinical practice. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health. c 2015 by the American College of Nurse-Midwives. J Midwifery Womens Health 2015;60:291–297 Keywords: faculty development, midwifery education, team-based learning
INTRODUCTION
Several national organizations have stated that traditional education methods, using lecture and relying on student memorization, fail to adequately prepare nurses for current health care realities. These organizations call for new and innovative classroom models that are learner-centered and competencybased.1–3 Collectively, these calls provide a vision for health care education that goes beyond knowledge acquisition and prepares learners to provide high-quality care in dynamic, team-based environments. However, research is lacking on how these innovative education models work, especially in health care education. The International Confederation of Midwives calls for a competency-based approach to midwifery education,4 and the American College of Nurse-Midwives has a set of core competencies for graduates of accredited midwifery programs, which includes “collaboration with other members of the interprofessional health care team” as a hallmark of midwifery.5 Additionally, accreditation criteria for US midwifery education programs specify that curricular components be delivered by “a variety of [teaching] methods to achieve the program objectives/outcomes and ensure student learning.”6 However, there is currently no requirement for collaborative classroom education.
A variety of innovative educational methods have been proposed, including team-based learning, an educational method developed by Dr. Larry Michaelsen in the 1990s to encourage deep learning and interaction with content on multiple levels.7 Team-based learning involves intensive preclass student preparation, an assessment of student knowledge at the beginning of class, and use of classroom time to apply learned concepts using carefully constructed learning activities. Team-based learning allows students to apply course content through collegial interactions, and its modalities are consistent with current education reform mandates. This article describes the implementation of team-based learning in a master’s-level, nurse-midwifery, didactic, antepartum course. Course design, implementation, and evaluation of outcomes are presented.
Background
Address correspondence to Tonia L. Moore-Davis, CNM, MSN, Vanderbilt University School of Nursing, 461 21st Ave South, Nashville, TN 37240. E-mail: [email protected]
Team-based learning is a faculty-led educational method that uses multiple small groups within a single classroom space. Course organization, in this design, is based on 3 phases of student learning: preclass preparation, assessment of readiness to apply learned concepts, and content application through small-group activities.7 Emphasis is placed on application of concepts in a variety of complex scenarios, which require students to use concepts broadly and under realistic conditions. Seven elements make up the core design of teambased learning (Table 1).
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✦ Team-based learning is an educational method that has been used in health care education to encourage learners to apply knowledge to complex clinical situations. ✦ This is a report of the implementation of team-based learning in a master’s-level, nurse-midwifery didactic course. ✦ Student performance in midwifery coursework and on the American Midwifery Certification Board certification examination was similar before and after the implementation of the team-based learning model. ✦ Team-based learning is a reasonable teaching approach to prepare midwifery students for professional practice, but more research is needed. Team-based learning shares several similarities with problem-based learning, another educational method that may be familiar to faculty in health care education. Both methods rely on relevant, realistic problems and small group learning. However, several key differences between these methods have been described.8,9 The most significant difference between these approaches is the number of faculty facilitators needed. In team-based learning, one faculty member can facilitate many learning teams simultaneously, whereas in problem-based learning, each small group requires its own faculty facilitator.8 This particular aspect may make team-based learning a more feasible option for many education programs. Two systematic reviews demonstrate that, whereas students and faculty generally have positive reviews of teambased learning, the research on this method has several methodological problems.10,11 Published reports describe wide variation in model fidelity; core design elements of team-based learning are often missing or modified. In addition, there are no well-controlled multisite trials of the method. Outcome variables including subjective learner reviews and knowledge-based measures are not standardized, making comparisons difficult. Learner and faculty reviews of team-based learning are also inconclusive, with systematic reviews reporting positive11 and mixed learner reviews.10 In addition, it appears that learner knowledge is either increased or unchanged in team-based learning classes when compared with traditional lecture-based formats.10 Initial development of team-based learning materials is time-consuming, and the shift in teaching strategies may require faculty development.12 As with any education innovation, guidance for new adopters is important to model success. The nurse-midwifery faculty at Vanderbilt University chose to adopt team-based learning as a model to increase opportunities for students to apply content and collaborate with peers. Prior to implementing team-based learning in the didactic antepartum course, faculty revised a different didactic course to use recorded lectures for offsite learning in an effort to free up class time for interactive group work.13 A clinical course was also reformatted with a specific focus on incorporating more collaborative learning activities.14 Both of these course revisions were well received by students, and faculty wanted to continue to apply innovative, collaborative learning models in additional courses. The didactic antepartum course was 292
selected for implementation of team-based learning for several reasons, the most significant being that the course was taught on-site and contained a large volume of content unfamiliar to most students. METHODS
Vanderbilt University is a private, research-intensive university, located in an urban area of the southeastern United States. The nurse-midwifery education program maintains an average cohort of 20 to 25 students. Entry options are available for nurses and nonnurses. Those students entering without a nursing degree receive a one-year, baccalaureate-equivalent nursing education prior to graduate-level nurse-midwifery education. All program graduates are awarded a master of science in nursing Courses within the nurse-midwifery program include didactic, clinical, simulation, and laboratory experiences. Delivery of didactic content is varied and includes synchronous and asynchronous lectures and self-study learning modules. All online content is housed in a course platform from Blackboard, Inc. (Washington, DC). The full-time nurse-midwifery program is 4 semesters in length. During the first 2 semesters, classes are held oncampus several days each week. The last 2 semesters use modified-distance format with on-campus classes for 2 to 4 weeks at the start of each semester, followed by distance learning for the remainder of the course. Implementation of Team-Based Learning Core Elements
Team-based learning is a structured educational method with set components. Nurse-midwifery faculty at Vanderbilt University chose to simultaneously implement all core elements of team-based learning across the antepartum course. However, based on student feedback and academic performance, modifications were made over time to better meet students’ learning needs. Although model fidelity is problematic for educational research, the goal of the course revision was to improve student learning. All deviations from the model are detailed for clarity. Team Formation
Use of small learning groups of approximately 5 to 7 students with diverse skills and knowledge, known as resources, is an essential component of team-based learning.7 These small Volume 60, No. 3, May/June 2015
Table 1. Core Elements of Team-Based Learning
Core Element Team formation
Description Faculty-led formation of groups composed of 5-8 students, with special attention given to equitable yet heterogeneous
learning groups were formed during the first class session and remained constant through out the semester to allow students opportunity to foster collaboration skills. According to Michaelsen, important interpersonal resources should be divided across groups7 ; therefore, faculty distributed students with previous maternal-child health nursing experience equitably among groups.
group composition Readiness assurance
Verification of individual and team knowledge and assessment of student readiness to apply course concepts to complex, in-class learning activities
Immediate feedback
Correct answers from the readiness assurance tests are revealed during group assessment process, allowing students to discuss key concepts, learn from
Preclass Student Resources
Michaelsen’s model encourages faculty to provide comprehensive, in-depth readings for students to use in preclass preparation but does not include faculty lectures.7 However, at the midterm course evaluation for the first team-based learning cohort, students stated that it was difficult to synthesize course concepts from readings alone. In response, faculty provided brief, recorded lectures on key content and added these as a resource for preclass preparation. Recorded lectures were designed to highlight key concepts and aid students in synthesizing knowledge rather than providing a comprehensive overview of each topic.
one another, and develop communication skills Sequencing of in-class problem solving
Progression from within-team learning activities that promote effective communication and consensus building to broader cross-groups discussion that encourages engagement with constructive controversy
4 Ss
Key features of in-class learning activities: significant problem, same problem, specific choice, simultaneous reporting
Incentive structure
Incorporation of grading elements that motivate students toward preclass preparations and effective, in-class team collaboration
Peer evaluation
Use of peer-to-peer and group-to-group feedback mechanisms to promote individual accountability for preparation and participation, as well as aid in the development of appropriate assertiveness and
Readiness Assurance Tests
Consistent with Michaelsen’s model, a 2-step method of readiness assessment was used, including an individual assessment and a team assessment.7 Individual assessments consisted of 10 multiple-choice questions written at the level of knowledge or basic application and addressed content from preclass readings. Students were given 10 minutes at the start of class to complete the individual assessment. Team assessments were conducted immediately following the individual assessments and used the same questions. Groups were given 15 minutes to debate answers and reach consensus for each question. Immediate Feedback Assessment Technique forms were used to provide feedback on correct answers during the team assessment. Immediate Feedback Assessment Technique forms are multiple-choice answer forms with scratch-off boxes corresponding to the number of assessment questions and answer choices.15 Student groups are instructed to scratch off the opaque, waxy coating from the boxes to indicate their answer selection. Revealing a star indicated a correct answer; a blank space indicated an incorrect answer. Groups continued scratching off additional answer selections, as needed, until the correct answer was revealed. These customized scratchoff cards, similar to lottery tickets, were well received by students and highly effective in promoting learning.16 Team assessment scores were calculated based on the number of attempts needed to reveal the correct answer. Students could challenge the correct answer by sending a referenced rationale to course faculty.
collaboration Sources: Haidet et al18 and Michaelsen et al.7
Team Application Activities
Most in-class group activities involved students applying concepts from course content to faculty-generated cases. Cases were based on real antepartum clinical encounters, and pertinent data were presented realistically as mock charts. Other assignments included the creation of algorithms to guide practice and differentiate normal from pathologic conditions. Journal of Midwifery & Women’s Health r www.jmwh.org
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Michaelsen’s model emphasizes that groups are to work simultaneously on the same activity and reveal their products in unison.7 However, faculty were concerned that this approach limited the number of topics that could be covered during class time. In subsequent cohorts of team-based learning, faculty trialed the use of different cases across groups. This also was found to be problematic because there was a loss of student engagement in the interteam discussions when cases differed across groups. Faculty eventually revamped the complexity of the cases and returned to using the same case for all groups. Teams used dry-erase whiteboards and large format flipcharts to display products from group activities in unison. Team-based learning has a strong emphasis on feedback. In this model, students provide feedback in both group-togroup and peer-to-peer formats. In the first year, model fidelity was maintained and groups provided feedback to other groups using stickers that depicted stars and squawks. Stars denoted exemplary work; squawks were assigned to substandard products. Groups were assigned group activity grades based on the number of stars and squawks received. However, on the mid-semester course evaluation with the first cohort, students strongly disliked assigning stars and squawks in class, stating that it discouraged them from taking risks with their group work. They especially disliked negatively affecting colleagues’ grades. With subsequent cohorts, group-to-group feedback was eliminated.
Peer Evaluation
The Michaelsen method of peer evaluation calls for each student to assign individual teammates a score based on perceived contribution to the group process.7 Peer review was conducted 3 to 4 times per semester and used to statistically adjust each student’s team-activity grade. Students were asked to assess the contribution of each team member on preparation for class, contribution to group effort, respect for differing opinions, and flexibility in reaching group consensus. Each student was allotted 100 points to distribute among team members. Exemplary team members were rewarded with more points compared to less-engaged members. Students were also asked to provide qualitative feedback to each team member by responding to 2 structured questions: What is the single most valuable contribution this person makes to your team? What is the single most important way this person could alter their behavior to more effectively help your team? Faculty compiled peer evaluation points and qualitative responses, disseminating them to individual students in aggregate to make the feedback anonymous.
RESULTS
Team-based learning has been used in 3 cohorts of students. A total of 70 students have completed the revised course format. The demographic characteristics of the students enrolled in the course mirrored the overall demographics of the nurse-midwifery student population. The majority of enrolled students were non-Hispanic, white females, with approximately 20% of students identifying as a member of a minority
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Table 2. Student Grades Before and After Team-Based Learning Course Revision
Student Final
Cohorts Prior to
Cohorts Receiving
Course Grade
Course Revision
Team-Based Learning
A
36%
25.7%
B
62%
68.6%
C and below
1.6%
5.7%
group. Less than 1% of the student population was male. The average student age was 28 years. A tracking feature of the online learning platform allowed faculty to monitor individual access and student engagement with the preclass readings; however, this measure is imprecise. Most students accessed the course resources prior to class and seemed to be well prepared. Student scores on individual assessments varied by week and content complexity, but averaged 80%. Team assessment scores usually exceeded the individual assessment scores, with groups rarely scoring less than 95% on the team assessment. Following the course revision, student performance on the course examinations and American Midwifery Certification Board (AMCB) certification examination were closely monitored. It was difficult to make conclusive statements about student outcomes due to confounding variables, including changes in testing and assessment, unrelated to the teaching methods. In addition, student cohorts varied in their learning styles and previous knowledge levels. However, although rigid statistical comparisons lack validity, we did compare the achievement of the 3 cohorts of students in the team-based learning class model with the 3 previous cohorts. Sixty-one students completed the antepartum course prior to the revision, and 70 students completed the revised course. Course grades and AMCB certification examination outcomes were used to measure student performance. Results were similar for groups before and after the team-based learning revision. Student course grades before and after the revision are shown in Table 2. The course grades prior to the revision were based solely on test scores; and after the revision, 75% of the course grades were based on tests. However, the tests changed from year to year, making it difficult to compare scores across cohorts. Beyond test scores, the number of students withdrawing for academic reasons was comparable between the 2 groups, but low numbers prevent disclosure to protect student identity. The AMCB certification examination is a nationally recognized test of midwifery preparation for practice. Data concerning student performance on the AMCB certification examination are released each year in aggregate form by school. Only data from the 2013 AMCB certification examination were available for comparison. In general, aggregate pass rates for graduates of the program were very high and remained comparable throughout the revision process. Although there were minimal changes in objective measures or test scores, student evaluations of the course provided valuable information. Student reviews of the course revision
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were mixed. Some students praised the new format, and others expressed frustration with the new model, especially the self-directed nature of learning required in the team-based format. Comments of frustration were particularly prevalent before the faculty included preclass recorded lectures. Course evaluations were standardized across all master’slevel courses at Vanderbilt University and included a combination of Likert-style responses and write-in comments. Students were asked to rate a series of statements about teaching methods, course content, and facilitation of learning using a 5-point scale. Five indicated strong agreement, and one indicated strong disagreement. Student course evaluations from the 3 years preceding the revision were reviewed and compared with the evaluations from the 3 cohorts receiving teambased learning. The evaluations from the 3 nonteam-based learning cohorts were positive, without requests for dramatic course changes. The Likert-type evaluation responses showed that students were pleased with the overall content and teaching methods for the course, with 85% of students noting the teaching methods were “helpful for [their] learning style.” In the 3 years after the course revision, 51% of students stated that the teaching methods were “helpful” or “facilitated [their] learning.” Write-in responses demonstrated that some students had strong opinions for or against the team-based learning format. The comments for and against the overall course format were approximately equal when all team-based learning cohorts were reviewed. However, the first cohort of students had more negative comments when compared with later cohorts, but students mentioned that the addition of recorded lectures improved their ability to master course content. In the writein responses from the team-based learning cohorts, several students mentioned that although they initially disliked the group work, they learned new communication and collaboration skills in the process. However, there were no objective measures available to capture this growth. Students also mentioned that, although they initially disliked the individual assessments and team assessments, these items forced them to come prepared for class. In all of the team-based learning cohorts, students did not like taking the assessment tests without having prior faculty input, such as a recorded lecture or an in-class question-and-answer session. Students stated they were unable to determine the important components of the readings without faculty assistance and that sources often had conflicting information. Faculty perceptions of the model were generally positive. Students came to class prepared, and in-class discussions tended to be deep and positive. Student questions exceeded faculty expectations, and faculty were impressed by the additional, noncourse-related skills that students learned through the course. For instance, students in each cohort were initially frustrated with conflicting information in preclass resources but developed the ability to critically appraise sources over the course of the semester. Students also appeared to learn how to work with those peers with different communication styles than their own. Those who were quiet natured were encouraged to be more outspoken, and those who were outspoken were encouraged to listen. The faculty time and effort needed for team-based learning format was greater than for a lecture-based course, Journal of Midwifery & Women’s Health r www.jmwh.org
especially during the implementation phase of this format. Initially, faculty had to prepare the cases and readiness assurance tests in addition to updating readings, lectures, and examinations, as would be required in a lecture-only course. However, subsequent offerings of the course only required updates, but each component of the course needed to be checked for congruence with current guidelines. DISCUSSION
Team-based learning is a well-described approach to course design and learning and is consistent with current recommendations for innovative health care education.3 Students have the opportunity to collaborate in small groups and to apply course content to complex cases or activities constructed by faculty. However, it is difficult to measure the effects of this model on student progress toward core midwifery competencies and even more challenging to address long-term effects on collaboration skills.4,5 Whereas students and faculty perceived that the model improved communication and collaboration skills, this was difficult to assess objectively because no tested measures are available. Additionally, although performance on course tests and the AMCB certification examination was not substantially improved with the new course format, it was not lower. There are several limitations to our initial analysis of team-based learning implementation, including poor model fidelity, lack of validated measures of student collaboration and communication skills, and a small sample size. However, our experiences with the model may be valuable to other midwifery faculty as they strive to meet educational standards and provide energetic learning environments. Model fidelity may have been a disadvantage for students in this type of curriculum or with students new to the health care field. Consistent with the literature, initial reformatting of a course to the team-based learning model required substantial faculty effort; but once established, the model is not difficult to sustain.7,12 Faculty should consider asking for extra workload for the first year of a team-based learning course revision. Alternatively, faculty could reformat and test the model with a single class session, adding additional classes or sessions in the new format over time. Administrative support for course revision is important because some schools rely heavily on student feedback to assess quality of instruction, and student evaluation scores notably decreased with the first team-based learning cohort. The lowest evaluation was the midterm evaluation of the first cohort. However, with changes to the team-based learning model, the student evaluations improved. New educational models, although not initially pleasing to students, may still enhance their learning. There is debate within the education community on how to measure the success of courses that fundamentally challenge the way that students learn, think, and interact.17 However, the faculty needs administrative support to take this risk.12 Whereas this course revision originally attempted to implement all team-based learning elements in a didactic course, modifications were needed to meet student needs. Other faculty could modify the team-based learning model to provide grouplearning opportunities without changing the overall course structure. 295
CONCLUSION
CONFLICT OF INTEREST
New and innovative educational models are needed to prepare midwifery students for practice in collaborative clinical environments. Team-based learning is an educational approach that encourages students to improve their communication and collaboration skills while applying their knowledge. However, the dynamic nature of educational interventions makes systematic study of student outcomes difficult. This revision of a nurse-midwifery, didactic antepartum course demonstrated that the format is compatible with midwifery education but failed to find substantial benefits over lecture-based instruction. Student achievement on structured course examinations and the AMCB certification examination has remained stable following implementation of a team-based learning model. Students and faculty believe communication and collaboration skills were improved with this course format. Midwifery faculty desiring greater student engagement with course content should consider team-based learning. Although model fidelity is important for research purposes, student-learning needs may be more important than model adherence. The implementation of team-based learning in the didactic antepartum course at Vanderbilt University included multiple modifications to address student concerns and learning needs, limiting the generalizability of findings to other instances of team-based learning use. Future research should focus on long-term student outcomes postgraduation and at intervals during the early career transition into professional midwifery practice. In addition, the development of valid measures of communication and collaboration skills would provide valuable information on the effectiveness of this model in midwifery education. Team-based learning has some advantages when compared to traditional lecture-based course formats. However, there are little conclusive data to support that this model is more effective than current models in preparing students for clinical practice.
The authors have no conflicts of interest to disclose.
AUTHORS
Tonia L. Moore-Davis, CNM, MSN, is Instructor of Nursing at Vanderbilt University, Nashville, Tennessee, where she teaches master’s students and practices midwifery. Mavis N. Schorn, CNM, PhD, FACNM, is Senior Associate Dean for Academics. As a professor, she teaches and practices midwifery at Vanderbilt University School of Nursing, Nashville, Tennessee. Michelle R. Collins, CNM, PhD, FACNM, is Associate Professor at Vanderbilt University School of Nursing, Nashville, Tennessee, where she teaches master’s and doctoral students and practices midwifery. Julia C. Phillippi, CNM, PhD, FACNM, is Assistant Professor at Vanderbilt University School of Nursing, Nashville, Tennessee, where she teaches master’s and doctoral students and practices midwifery. Sharon L. Holley, CNM, DNP, is an Assistant Professor at Vanderbilt University School of Nursing, Nashville, Tennessee, where she teaches master’s and doctoral students and practices midwifery. 296
REFERENCES 1.Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. 2.Benner PE, Sutphen M, Leonard V, Day L. Educating Nurses: A Call For Radical Transformation. San Francisco, CA: Jossey-Bass; 2010. 3.American Association of Colleges of Nursing. Lifelong Learning in Medicine and Nursing: Final Conference Report. Washington, DC: American Association of Colleges of Nursing; 2010. 4.International Confederation of Midwives. Essential competencies for basic midwifery practice. International Confederation of Midwives Web site. http://www.internationalmidwives.org/whatwe-do/education-coredocuments/essential-competencies-basicmidwifery-practice./ Updated 2013. Accessed June 27, 2014. 5.American College of Nurse-Midwives. Core competencies for basic midwifery practice. Silver Spring, MD: American College of Nurse-Midwives Web site. http://www.midwife.org/ACNM/files/ ACNMLibraryData/UPLOADFILENAME/000000000050/Core Comptencies Dec 2012.pdf. Published December 2012. Updated July 2014. Accessed July 14, 2014. 6.Accreditation Commission for Midwifery Education. Criteria for Programmatic Accreditation of Midwifery Education Programs with Instructions for Elaboration and Documentation. Silver Spring, MD: Accreditation Commission for Midwifery Education Web site. http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/ 000000004249/AccreditationCriteriaJune2013.pdf. Published June 2013. Updated July 2014. Accessed July 14, 2014. 7.Michaelsen L, Parmelee D, McMahon K, Levine R, eds. Team-Based Learning for Health Professions Education: A Guide to Using Small Groups for Improving Learning. Sterling, VA: Stylus Publishing; 2007. 8.Dolmans D, Michaelsen L, Van Merienboer J, van der Vleuten C. Should we choose between problem-based learning and team-based learning? No, combine the best of both worlds! Med Teach. 2014;0: 1-6. 9.Parmelee D, Michaelsen LK, Cook S, Hudes PD. Team-based learning: A practical guide: AMEE Guide No. 65. Med Teach. 2012;34(5):e275e287. 10.Fatmi M, Hartling L, Hillier T, Campbell S, Oswald AE. The effectiveness of team-based learning on learning outcomes in health professions education: BEME Guide No. 30. Med Teach. 2013;35(12): e1608-e1624. 11.Burgess AW, McGregor DM, Mellis CM. Applying established guidelines to team-based learning programs in medical schools: A systematic review. Acad Med. 2014;89(4):678-688. 12.Andersen EA, Strumpel C, Fensom I, Andrews W. Implementing team based learning in large classes: Nurse educators’ experiences. Int J Nurs Educ Scholarsh [serial online] 2011; 8(1):1548. doi: 10.2202/1548-923X.2197. Available from: http://www.ncbi. nlm.nih.gov/pubmed/22499709. Accessed June 4, 2014. 13.Phillippi JC, Schorn MN. Course revision: From unidirectional knowledge to dynamic application. J Nurs Educ. 2011;50(7):410413. 14.Phillippi JC, Bull A, Holley SL. Expanding primary care opportunities: Simulation for clinical reasoning. J Nurs Educ. 2013;52(5):299302. 15.Epstein ML, Epstein BB, Brosvic GM. Immediate feedback during academic testing. Psychol Rep. 2001;88:889-894. 16.Epstein ML, Lazarus AD, Calvano TB, et al. Immediate feedback assessment technique promotes learning and corrects inaccurate first responses. Psychol Rec. 2002;52:187-201. Volume 60, No. 3, May/June 2015
17.Spooren P, Brockx B, Mortelmans D. On the validity of student evaluation of teaching: The state of the art. Rev Educ Res. 2013;83(4):598642. 18.Haidet P, Levine RE, Parmelee DX, et al. Guidelines for reporting team-based learning activities in the medical and health sciences education literature. Acad Med. 2012;87(3):292-299.
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Original Research
Team-Based Learning for Midwifery Education Tonia L. Moore-Davis, CNM, MSN, Mavis N. Schorn, CNM, PhD, Michelle R. Collins, CNM, PhD, Julia Phillippi, CNM, PhD, Sharon Holley, CNM, DNP
CEU
Introduction: Many US health care and education stakeholder groups, recognizing the need to prepare learners for collaborative practice in complex care environments, have called for innovative approaches in health care education. Team-based learning is an educational method that relies on in-depth student preparation prior to class, individual and team knowledge assessment, and use of small-group learning to apply knowledge to complex scenarios. Although team-based learning has been studied as an approach to health care education, its application to midwifery education is not well described. Methods: A master’s-level, nurse-midwifery, didactic antepartum course was revised to a team-based learning format. Student grades, course evaluations, and aggregate American Midwifery Certification Board examination pass rates for 3 student cohorts participating in the team-based course were compared with 3 student cohorts receiving traditional, lecture-based instruction. Results: Students had mixed responses to the team-based learning format. Student evaluations improved when faculty added recorded lectures as part of student preclass preparation. Statistical comparisons were limited by variations across cohorts; however, student grades and certification examination pass rates did not change substantially after the course revision. Although initial course revision was time-consuming for faculty, subsequent iterations of the course required less effort. Discussion: Team-based learning provides students with more opportunity to interact during on-site classes and may spur application of knowledge into practice. However, it is difficult to assess the effect of the team-based learning approach with current measures. Further research is needed to determine the effects of team-based learning on communication and collaboration skills, as well as long-term performance in clinical practice. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health. c 2015 by the American College of Nurse-Midwives. J Midwifery Womens Health 2015;60:291–297 Keywords: faculty development, midwifery education, team-based learning
INTRODUCTION
Several national organizations have stated that traditional education methods, using lecture and relying on student memorization, fail to adequately prepare nurses for current health care realities. These organizations call for new and innovative classroom models that are learner-centered and competencybased.1–3 Collectively, these calls provide a vision for health care education that goes beyond knowledge acquisition and prepares learners to provide high-quality care in dynamic, team-based environments. However, research is lacking on how these innovative education models work, especially in health care education. The International Confederation of Midwives calls for a competency-based approach to midwifery education,4 and the American College of Nurse-Midwives has a set of core competencies for graduates of accredited midwifery programs, which includes “collaboration with other members of the interprofessional health care team” as a hallmark of midwifery.5 Additionally, accreditation criteria for US midwifery education programs specify that curricular components be delivered by “a variety of [teaching] methods to achieve the program objectives/outcomes and ensure student learning.”6 However, there is currently no requirement for collaborative classroom education.
A variety of innovative educational methods have been proposed, including team-based learning, an educational method developed by Dr. Larry Michaelsen in the 1990s to encourage deep learning and interaction with content on multiple levels.7 Team-based learning involves intensive preclass student preparation, an assessment of student knowledge at the beginning of class, and use of classroom time to apply learned concepts using carefully constructed learning activities. Team-based learning allows students to apply course content through collegial interactions, and its modalities are consistent with current education reform mandates. This article describes the implementation of team-based learning in a master’s-level, nurse-midwifery, didactic, antepartum course. Course design, implementation, and evaluation of outcomes are presented.
Background
Address correspondence to Tonia L. Moore-Davis, CNM, MSN, Vanderbilt University School of Nursing, 461 21st Ave South, Nashville, TN 37240. E-mail: [email protected]
Team-based learning is a faculty-led educational method that uses multiple small groups within a single classroom space. Course organization, in this design, is based on 3 phases of student learning: preclass preparation, assessment of readiness to apply learned concepts, and content application through small-group activities.7 Emphasis is placed on application of concepts in a variety of complex scenarios, which require students to use concepts broadly and under realistic conditions. Seven elements make up the core design of teambased learning (Table 1).
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✦ Team-based learning is an educational method that has been used in health care education to encourage learners to apply knowledge to complex clinical situations. ✦ This is a report of the implementation of team-based learning in a master’s-level, nurse-midwifery didactic course. ✦ Student performance in midwifery coursework and on the American Midwifery Certification Board certification examination was similar before and after the implementation of the team-based learning model. ✦ Team-based learning is a reasonable teaching approach to prepare midwifery students for professional practice, but more research is needed. Team-based learning shares several similarities with problem-based learning, another educational method that may be familiar to faculty in health care education. Both methods rely on relevant, realistic problems and small group learning. However, several key differences between these methods have been described.8,9 The most significant difference between these approaches is the number of faculty facilitators needed. In team-based learning, one faculty member can facilitate many learning teams simultaneously, whereas in problem-based learning, each small group requires its own faculty facilitator.8 This particular aspect may make team-based learning a more feasible option for many education programs. Two systematic reviews demonstrate that, whereas students and faculty generally have positive reviews of teambased learning, the research on this method has several methodological problems.10,11 Published reports describe wide variation in model fidelity; core design elements of team-based learning are often missing or modified. In addition, there are no well-controlled multisite trials of the method. Outcome variables including subjective learner reviews and knowledge-based measures are not standardized, making comparisons difficult. Learner and faculty reviews of team-based learning are also inconclusive, with systematic reviews reporting positive11 and mixed learner reviews.10 In addition, it appears that learner knowledge is either increased or unchanged in team-based learning classes when compared with traditional lecture-based formats.10 Initial development of team-based learning materials is time-consuming, and the shift in teaching strategies may require faculty development.12 As with any education innovation, guidance for new adopters is important to model success. The nurse-midwifery faculty at Vanderbilt University chose to adopt team-based learning as a model to increase opportunities for students to apply content and collaborate with peers. Prior to implementing team-based learning in the didactic antepartum course, faculty revised a different didactic course to use recorded lectures for offsite learning in an effort to free up class time for interactive group work.13 A clinical course was also reformatted with a specific focus on incorporating more collaborative learning activities.14 Both of these course revisions were well received by students, and faculty wanted to continue to apply innovative, collaborative learning models in additional courses. The didactic antepartum course was 292
selected for implementation of team-based learning for several reasons, the most significant being that the course was taught on-site and contained a large volume of content unfamiliar to most students. METHODS
Vanderbilt University is a private, research-intensive university, located in an urban area of the southeastern United States. The nurse-midwifery education program maintains an average cohort of 20 to 25 students. Entry options are available for nurses and nonnurses. Those students entering without a nursing degree receive a one-year, baccalaureate-equivalent nursing education prior to graduate-level nurse-midwifery education. All program graduates are awarded a master of science in nursing Courses within the nurse-midwifery program include didactic, clinical, simulation, and laboratory experiences. Delivery of didactic content is varied and includes synchronous and asynchronous lectures and self-study learning modules. All online content is housed in a course platform from Blackboard, Inc. (Washington, DC). The full-time nurse-midwifery program is 4 semesters in length. During the first 2 semesters, classes are held oncampus several days each week. The last 2 semesters use modified-distance format with on-campus classes for 2 to 4 weeks at the start of each semester, followed by distance learning for the remainder of the course. Implementation of Team-Based Learning Core Elements
Team-based learning is a structured educational method with set components. Nurse-midwifery faculty at Vanderbilt University chose to simultaneously implement all core elements of team-based learning across the antepartum course. However, based on student feedback and academic performance, modifications were made over time to better meet students’ learning needs. Although model fidelity is problematic for educational research, the goal of the course revision was to improve student learning. All deviations from the model are detailed for clarity. Team Formation
Use of small learning groups of approximately 5 to 7 students with diverse skills and knowledge, known as resources, is an essential component of team-based learning.7 These small Volume 60, No. 3, May/June 2015
Table 1. Core Elements of Team-Based Learning
Core Element Team formation
Description Faculty-led formation of groups composed of 5-8 students, with special attention given to equitable yet heterogeneous
learning groups were formed during the first class session and remained constant through out the semester to allow students opportunity to foster collaboration skills. According to Michaelsen, important interpersonal resources should be divided across groups7 ; therefore, faculty distributed students with previous maternal-child health nursing experience equitably among groups.
group composition Readiness assurance
Verification of individual and team knowledge and assessment of student readiness to apply course concepts to complex, in-class learning activities
Immediate feedback
Correct answers from the readiness assurance tests are revealed during group assessment process, allowing students to discuss key concepts, learn from
Preclass Student Resources
Michaelsen’s model encourages faculty to provide comprehensive, in-depth readings for students to use in preclass preparation but does not include faculty lectures.7 However, at the midterm course evaluation for the first team-based learning cohort, students stated that it was difficult to synthesize course concepts from readings alone. In response, faculty provided brief, recorded lectures on key content and added these as a resource for preclass preparation. Recorded lectures were designed to highlight key concepts and aid students in synthesizing knowledge rather than providing a comprehensive overview of each topic.
one another, and develop communication skills Sequencing of in-class problem solving
Progression from within-team learning activities that promote effective communication and consensus building to broader cross-groups discussion that encourages engagement with constructive controversy
4 Ss
Key features of in-class learning activities: significant problem, same problem, specific choice, simultaneous reporting
Incentive structure
Incorporation of grading elements that motivate students toward preclass preparations and effective, in-class team collaboration
Peer evaluation
Use of peer-to-peer and group-to-group feedback mechanisms to promote individual accountability for preparation and participation, as well as aid in the development of appropriate assertiveness and
Readiness Assurance Tests
Consistent with Michaelsen’s model, a 2-step method of readiness assessment was used, including an individual assessment and a team assessment.7 Individual assessments consisted of 10 multiple-choice questions written at the level of knowledge or basic application and addressed content from preclass readings. Students were given 10 minutes at the start of class to complete the individual assessment. Team assessments were conducted immediately following the individual assessments and used the same questions. Groups were given 15 minutes to debate answers and reach consensus for each question. Immediate Feedback Assessment Technique forms were used to provide feedback on correct answers during the team assessment. Immediate Feedback Assessment Technique forms are multiple-choice answer forms with scratch-off boxes corresponding to the number of assessment questions and answer choices.15 Student groups are instructed to scratch off the opaque, waxy coating from the boxes to indicate their answer selection. Revealing a star indicated a correct answer; a blank space indicated an incorrect answer. Groups continued scratching off additional answer selections, as needed, until the correct answer was revealed. These customized scratchoff cards, similar to lottery tickets, were well received by students and highly effective in promoting learning.16 Team assessment scores were calculated based on the number of attempts needed to reveal the correct answer. Students could challenge the correct answer by sending a referenced rationale to course faculty.
collaboration Sources: Haidet et al18 and Michaelsen et al.7
Team Application Activities
Most in-class group activities involved students applying concepts from course content to faculty-generated cases. Cases were based on real antepartum clinical encounters, and pertinent data were presented realistically as mock charts. Other assignments included the creation of algorithms to guide practice and differentiate normal from pathologic conditions. Journal of Midwifery & Women’s Health r www.jmwh.org
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Michaelsen’s model emphasizes that groups are to work simultaneously on the same activity and reveal their products in unison.7 However, faculty were concerned that this approach limited the number of topics that could be covered during class time. In subsequent cohorts of team-based learning, faculty trialed the use of different cases across groups. This also was found to be problematic because there was a loss of student engagement in the interteam discussions when cases differed across groups. Faculty eventually revamped the complexity of the cases and returned to using the same case for all groups. Teams used dry-erase whiteboards and large format flipcharts to display products from group activities in unison. Team-based learning has a strong emphasis on feedback. In this model, students provide feedback in both group-togroup and peer-to-peer formats. In the first year, model fidelity was maintained and groups provided feedback to other groups using stickers that depicted stars and squawks. Stars denoted exemplary work; squawks were assigned to substandard products. Groups were assigned group activity grades based on the number of stars and squawks received. However, on the mid-semester course evaluation with the first cohort, students strongly disliked assigning stars and squawks in class, stating that it discouraged them from taking risks with their group work. They especially disliked negatively affecting colleagues’ grades. With subsequent cohorts, group-to-group feedback was eliminated.
Peer Evaluation
The Michaelsen method of peer evaluation calls for each student to assign individual teammates a score based on perceived contribution to the group process.7 Peer review was conducted 3 to 4 times per semester and used to statistically adjust each student’s team-activity grade. Students were asked to assess the contribution of each team member on preparation for class, contribution to group effort, respect for differing opinions, and flexibility in reaching group consensus. Each student was allotted 100 points to distribute among team members. Exemplary team members were rewarded with more points compared to less-engaged members. Students were also asked to provide qualitative feedback to each team member by responding to 2 structured questions: What is the single most valuable contribution this person makes to your team? What is the single most important way this person could alter their behavior to more effectively help your team? Faculty compiled peer evaluation points and qualitative responses, disseminating them to individual students in aggregate to make the feedback anonymous.
RESULTS
Team-based learning has been used in 3 cohorts of students. A total of 70 students have completed the revised course format. The demographic characteristics of the students enrolled in the course mirrored the overall demographics of the nurse-midwifery student population. The majority of enrolled students were non-Hispanic, white females, with approximately 20% of students identifying as a member of a minority
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Table 2. Student Grades Before and After Team-Based Learning Course Revision
Student Final
Cohorts Prior to
Cohorts Receiving
Course Grade
Course Revision
Team-Based Learning
A
36%
25.7%
B
62%
68.6%
C and below
1.6%
5.7%
group. Less than 1% of the student population was male. The average student age was 28 years. A tracking feature of the online learning platform allowed faculty to monitor individual access and student engagement with the preclass readings; however, this measure is imprecise. Most students accessed the course resources prior to class and seemed to be well prepared. Student scores on individual assessments varied by week and content complexity, but averaged 80%. Team assessment scores usually exceeded the individual assessment scores, with groups rarely scoring less than 95% on the team assessment. Following the course revision, student performance on the course examinations and American Midwifery Certification Board (AMCB) certification examination were closely monitored. It was difficult to make conclusive statements about student outcomes due to confounding variables, including changes in testing and assessment, unrelated to the teaching methods. In addition, student cohorts varied in their learning styles and previous knowledge levels. However, although rigid statistical comparisons lack validity, we did compare the achievement of the 3 cohorts of students in the team-based learning class model with the 3 previous cohorts. Sixty-one students completed the antepartum course prior to the revision, and 70 students completed the revised course. Course grades and AMCB certification examination outcomes were used to measure student performance. Results were similar for groups before and after the team-based learning revision. Student course grades before and after the revision are shown in Table 2. The course grades prior to the revision were based solely on test scores; and after the revision, 75% of the course grades were based on tests. However, the tests changed from year to year, making it difficult to compare scores across cohorts. Beyond test scores, the number of students withdrawing for academic reasons was comparable between the 2 groups, but low numbers prevent disclosure to protect student identity. The AMCB certification examination is a nationally recognized test of midwifery preparation for practice. Data concerning student performance on the AMCB certification examination are released each year in aggregate form by school. Only data from the 2013 AMCB certification examination were available for comparison. In general, aggregate pass rates for graduates of the program were very high and remained comparable throughout the revision process. Although there were minimal changes in objective measures or test scores, student evaluations of the course provided valuable information. Student reviews of the course revision
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were mixed. Some students praised the new format, and others expressed frustration with the new model, especially the self-directed nature of learning required in the team-based format. Comments of frustration were particularly prevalent before the faculty included preclass recorded lectures. Course evaluations were standardized across all master’slevel courses at Vanderbilt University and included a combination of Likert-style responses and write-in comments. Students were asked to rate a series of statements about teaching methods, course content, and facilitation of learning using a 5-point scale. Five indicated strong agreement, and one indicated strong disagreement. Student course evaluations from the 3 years preceding the revision were reviewed and compared with the evaluations from the 3 cohorts receiving teambased learning. The evaluations from the 3 nonteam-based learning cohorts were positive, without requests for dramatic course changes. The Likert-type evaluation responses showed that students were pleased with the overall content and teaching methods for the course, with 85% of students noting the teaching methods were “helpful for [their] learning style.” In the 3 years after the course revision, 51% of students stated that the teaching methods were “helpful” or “facilitated [their] learning.” Write-in responses demonstrated that some students had strong opinions for or against the team-based learning format. The comments for and against the overall course format were approximately equal when all team-based learning cohorts were reviewed. However, the first cohort of students had more negative comments when compared with later cohorts, but students mentioned that the addition of recorded lectures improved their ability to master course content. In the writein responses from the team-based learning cohorts, several students mentioned that although they initially disliked the group work, they learned new communication and collaboration skills in the process. However, there were no objective measures available to capture this growth. Students also mentioned that, although they initially disliked the individual assessments and team assessments, these items forced them to come prepared for class. In all of the team-based learning cohorts, students did not like taking the assessment tests without having prior faculty input, such as a recorded lecture or an in-class question-and-answer session. Students stated they were unable to determine the important components of the readings without faculty assistance and that sources often had conflicting information. Faculty perceptions of the model were generally positive. Students came to class prepared, and in-class discussions tended to be deep and positive. Student questions exceeded faculty expectations, and faculty were impressed by the additional, noncourse-related skills that students learned through the course. For instance, students in each cohort were initially frustrated with conflicting information in preclass resources but developed the ability to critically appraise sources over the course of the semester. Students also appeared to learn how to work with those peers with different communication styles than their own. Those who were quiet natured were encouraged to be more outspoken, and those who were outspoken were encouraged to listen. The faculty time and effort needed for team-based learning format was greater than for a lecture-based course, Journal of Midwifery & Women’s Health r www.jmwh.org
especially during the implementation phase of this format. Initially, faculty had to prepare the cases and readiness assurance tests in addition to updating readings, lectures, and examinations, as would be required in a lecture-only course. However, subsequent offerings of the course only required updates, but each component of the course needed to be checked for congruence with current guidelines. DISCUSSION
Team-based learning is a well-described approach to course design and learning and is consistent with current recommendations for innovative health care education.3 Students have the opportunity to collaborate in small groups and to apply course content to complex cases or activities constructed by faculty. However, it is difficult to measure the effects of this model on student progress toward core midwifery competencies and even more challenging to address long-term effects on collaboration skills.4,5 Whereas students and faculty perceived that the model improved communication and collaboration skills, this was difficult to assess objectively because no tested measures are available. Additionally, although performance on course tests and the AMCB certification examination was not substantially improved with the new course format, it was not lower. There are several limitations to our initial analysis of team-based learning implementation, including poor model fidelity, lack of validated measures of student collaboration and communication skills, and a small sample size. However, our experiences with the model may be valuable to other midwifery faculty as they strive to meet educational standards and provide energetic learning environments. Model fidelity may have been a disadvantage for students in this type of curriculum or with students new to the health care field. Consistent with the literature, initial reformatting of a course to the team-based learning model required substantial faculty effort; but once established, the model is not difficult to sustain.7,12 Faculty should consider asking for extra workload for the first year of a team-based learning course revision. Alternatively, faculty could reformat and test the model with a single class session, adding additional classes or sessions in the new format over time. Administrative support for course revision is important because some schools rely heavily on student feedback to assess quality of instruction, and student evaluation scores notably decreased with the first team-based learning cohort. The lowest evaluation was the midterm evaluation of the first cohort. However, with changes to the team-based learning model, the student evaluations improved. New educational models, although not initially pleasing to students, may still enhance their learning. There is debate within the education community on how to measure the success of courses that fundamentally challenge the way that students learn, think, and interact.17 However, the faculty needs administrative support to take this risk.12 Whereas this course revision originally attempted to implement all team-based learning elements in a didactic course, modifications were needed to meet student needs. Other faculty could modify the team-based learning model to provide grouplearning opportunities without changing the overall course structure. 295
CONCLUSION
CONFLICT OF INTEREST
New and innovative educational models are needed to prepare midwifery students for practice in collaborative clinical environments. Team-based learning is an educational approach that encourages students to improve their communication and collaboration skills while applying their knowledge. However, the dynamic nature of educational interventions makes systematic study of student outcomes difficult. This revision of a nurse-midwifery, didactic antepartum course demonstrated that the format is compatible with midwifery education but failed to find substantial benefits over lecture-based instruction. Student achievement on structured course examinations and the AMCB certification examination has remained stable following implementation of a team-based learning model. Students and faculty believe communication and collaboration skills were improved with this course format. Midwifery faculty desiring greater student engagement with course content should consider team-based learning. Although model fidelity is important for research purposes, student-learning needs may be more important than model adherence. The implementation of team-based learning in the didactic antepartum course at Vanderbilt University included multiple modifications to address student concerns and learning needs, limiting the generalizability of findings to other instances of team-based learning use. Future research should focus on long-term student outcomes postgraduation and at intervals during the early career transition into professional midwifery practice. In addition, the development of valid measures of communication and collaboration skills would provide valuable information on the effectiveness of this model in midwifery education. Team-based learning has some advantages when compared to traditional lecture-based course formats. However, there are little conclusive data to support that this model is more effective than current models in preparing students for clinical practice.
The authors have no conflicts of interest to disclose.
AUTHORS
Tonia L. Moore-Davis, CNM, MSN, is Instructor of Nursing at Vanderbilt University, Nashville, Tennessee, where she teaches master’s students and practices midwifery. Mavis N. Schorn, CNM, PhD, FACNM, is Senior Associate Dean for Academics. As a professor, she teaches and practices midwifery at Vanderbilt University School of Nursing, Nashville, Tennessee. Michelle R. Collins, CNM, PhD, FACNM, is Associate Professor at Vanderbilt University School of Nursing, Nashville, Tennessee, where she teaches master’s and doctoral students and practices midwifery. Julia C. Phillippi, CNM, PhD, FACNM, is Assistant Professor at Vanderbilt University School of Nursing, Nashville, Tennessee, where she teaches master’s and doctoral students and practices midwifery. Sharon L. Holley, CNM, DNP, is an Assistant Professor at Vanderbilt University School of Nursing, Nashville, Tennessee, where she teaches master’s and doctoral students and practices midwifery. 296
REFERENCES 1.Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. 2.Benner PE, Sutphen M, Leonard V, Day L. Educating Nurses: A Call For Radical Transformation. San Francisco, CA: Jossey-Bass; 2010. 3.American Association of Colleges of Nursing. Lifelong Learning in Medicine and Nursing: Final Conference Report. Washington, DC: American Association of Colleges of Nursing; 2010. 4.International Confederation of Midwives. Essential competencies for basic midwifery practice. International Confederation of Midwives Web site. http://www.internationalmidwives.org/whatwe-do/education-coredocuments/essential-competencies-basicmidwifery-practice./ Updated 2013. Accessed June 27, 2014. 5.American College of Nurse-Midwives. Core competencies for basic midwifery practice. Silver Spring, MD: American College of Nurse-Midwives Web site. http://www.midwife.org/ACNM/files/ ACNMLibraryData/UPLOADFILENAME/000000000050/Core Comptencies Dec 2012.pdf. Published December 2012. Updated July 2014. Accessed July 14, 2014. 6.Accreditation Commission for Midwifery Education. Criteria for Programmatic Accreditation of Midwifery Education Programs with Instructions for Elaboration and Documentation. Silver Spring, MD: Accreditation Commission for Midwifery Education Web site. http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/ 000000004249/AccreditationCriteriaJune2013.pdf. Published June 2013. Updated July 2014. Accessed July 14, 2014. 7.Michaelsen L, Parmelee D, McMahon K, Levine R, eds. Team-Based Learning for Health Professions Education: A Guide to Using Small Groups for Improving Learning. Sterling, VA: Stylus Publishing; 2007. 8.Dolmans D, Michaelsen L, Van Merienboer J, van der Vleuten C. Should we choose between problem-based learning and team-based learning? No, combine the best of both worlds! Med Teach. 2014;0: 1-6. 9.Parmelee D, Michaelsen LK, Cook S, Hudes PD. Team-based learning: A practical guide: AMEE Guide No. 65. Med Teach. 2012;34(5):e275e287. 10.Fatmi M, Hartling L, Hillier T, Campbell S, Oswald AE. The effectiveness of team-based learning on learning outcomes in health professions education: BEME Guide No. 30. Med Teach. 2013;35(12): e1608-e1624. 11.Burgess AW, McGregor DM, Mellis CM. Applying established guidelines to team-based learning programs in medical schools: A systematic review. Acad Med. 2014;89(4):678-688. 12.Andersen EA, Strumpel C, Fensom I, Andrews W. Implementing team based learning in large classes: Nurse educators’ experiences. Int J Nurs Educ Scholarsh [serial online] 2011; 8(1):1548. doi: 10.2202/1548-923X.2197. Available from: http://www.ncbi. nlm.nih.gov/pubmed/22499709. Accessed June 4, 2014. 13.Phillippi JC, Schorn MN. Course revision: From unidirectional knowledge to dynamic application. J Nurs Educ. 2011;50(7):410413. 14.Phillippi JC, Bull A, Holley SL. Expanding primary care opportunities: Simulation for clinical reasoning. J Nurs Educ. 2013;52(5):299302. 15.Epstein ML, Epstein BB, Brosvic GM. Immediate feedback during academic testing. Psychol Rep. 2001;88:889-894. 16.Epstein ML, Lazarus AD, Calvano TB, et al. Immediate feedback assessment technique promotes learning and corrects inaccurate first responses. Psychol Rec. 2002;52:187-201. Volume 60, No. 3, May/June 2015
17.Spooren P, Brockx B, Mortelmans D. On the validity of student evaluation of teaching: The state of the art. Rev Educ Res. 2013;83(4):598642. 18.Haidet P, Levine RE, Parmelee DX, et al. Guidelines for reporting team-based learning activities in the medical and health sciences education literature. Acad Med. 2012;87(3):292-299.
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Continuing education units (CEUs) for this article are offered as part of a CEU theme issue. To obtain CEUs online, please visit www.jmwhce.org. A CEU form that can be mailed or faxed is available in the print edition of the theme issue.
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