Implementation of team-based learning on a large scale: Three factors to keep in mind* Implementation of team-based learning on a large scale: Three factors to keep in mind Ã

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  Team-based learning (TBL) is a structured form of small group learning that can be scaled up for delivery in large classes. The principles of successful TBL implementation are well established. TBL has become widely practiced in medical schools, but
  Full Terms & Conditions of access and use can be found at Medical Teacher ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: Implementation of team-based learning on a largescale: Three factors to keep in mind* Preman Rajalingam, Jerome I. Rotgans, Nabil Zary, Michael Alan Ferenczi,Paul Gagnon & Naomi Low-Beer To cite this article:  Preman Rajalingam, Jerome I. Rotgans, Nabil Zary, Michael Alan Ferenczi,Paul Gagnon & Naomi Low-Beer (2018): Implementation of team-based learning on a large scale:Three factors to keep in mind*, Medical Teacher, DOI: 10.1080/0142159X.2018.1451630 To link to this article: © 2018 The Author(s). Published by InformaUK Limited, trading as Taylor & FrancisGroupPublished online: 23 Mar 2018.Submit your article to this journal Article views: 364View related articles View Crossmark data  Implementation of team-based learning on a large scale: Three factors tokeep in mind  Preman Rajalingam, Jerome I. Rotgans, Nabil Zary, Michael Alan Ferenczi, Paul Gagnon and Naomi Low-Beer Medical Education Research and Scholarship Unit (MERSU), Lee Kong Chian School of Medicine, Singapore, Singapore ABSTRACT  Team-based learning (TBL) is a structured form of small group learning that can be scaled up for delivery in large classes. The principles of successful TBL implementation are well established. TBL has become widely practiced in medical schools,but its use is typically limited to certain courses or parts of courses. Implementing TBL on a large scale, across differentcourses and disciplines, is the next logical step. The Lee Kong Chian School of Medicine (LKCMedicine), a partnershipbetween Nanyang Technological University, Singapore and Imperial College London, admitted its first students in 2013. Thisnew undergraduate medical program, developed collaboratively by faculty at both institutions, uses TBL as its main learningand teaching strategy, replacing all face-to-face lectures. TBL accounts for over 60% of the curriculum in the first two years,and there is continued learning through TBL during campus teaching in the remaining years. This paper describes ourexperience of rolling out TBL across all years of the medical curriculum, focusing on three success factors: (1)  “ team-centric ” learning spaces, to foster active, collaborative learning; (2) an e-learning ecosystem, seamlessly integrated to support allphases of the TBL process and (3) teaching teams in which experts in pedagogical process (TBL Facilitators) co-teach withexperts in subject matter (Content Experts). Introduction In this paper, we describe the background to TBL and itsprinciples, our experience of developing a new TBL curricu-lum for delivery across all years of an undergraduatemedical program and three key developments that havecontributed to the success and sustainability of our approach. Team-based learning (TBL) is a structured form of smallgroup learning that can be scaled up for implementation inlarge classes. First developed by Larry Michaelsen in the1970s for use in graduate business education (Michaelsenet al. 2004), TBL has been widely adopted as an instruc-tional approach across many disciplines (Parmelee andHudes 2012). In a systematic review of TBL research inhealth professionals education, the majority of publishedstudies showed a positive effect of TBL in two areas com-pared to traditional lectures; (1) teacher and learner experi-ences and attitudes and (2) academic achievement ingraded assessments (Reimschisel et al. 2017). The principlesof TBL including its core design elements are well defined(Haidet et al. 2012), as are guidelines for its implementation(Parmelee et al. 2012). However, a systematic review of TBLimplementation found that in medical schools practicing TBL, its use was generally limited to a few sessions of asingle course (Burgess et al. 2014). The TBL process consists of three phases. In the prep-aration phase, individual learning is undertaken beforeclass. Learning resources may include journal articles, vid-eos or voiceover PowerPoints. The subsequent phasesoccur in class during which students are seated in teams. Teams typically number between 5 and 7 and team com-position should remain fixed for an extended period(Parmelee et al. 2012). The second phase is readiness assurance, where theintention is to ascertain whether students have acquiredsufficient understanding of the subject studied and toprovide clarifications where necessary. This starts with anindividual closed book knowledge test, in single bestanswer multiple-choice question (MCQ) format (IndividualReadiness Assurance Test or iRAT). Students then repeat Practice points   TBL may be successfully delivered across multiplecourses and in all years of an undergraduate med-ical curriculum.   Consistent delivery of TBL on a large scale bene-fits from a centrally managed curriculum team,with consistent adherence to established TBL principles.   Key factors that can contribute to the success of alarge-scale TBL curriculum include  “ team-centric ” learning spaces, an integrated e-learning ecosys-tem customized to support all phases of the TBLprocess, and teaching teams in which experts inpedagogical process (TBL Facilitators) co-teachwith experts in subject matter (Content Experts). CONTACT  Preman Rajalingam Nanyang Technological University, Lee Kong Chian School of Medicine, 11 Mandalay Road,Singapore 308232, Singapore  All research was conducted at Lee Kong Chian School of Medicine, a joint school of Nanyang Technological University, Singapore and Imperial CollegeLondon, UK.   2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis GroupThis is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the srcinal work is properly cited, and is not altered, transformed, or builtupon in any way. MEDICAL TEACHER, 2018  the same closed book test, but this time in their assignedteams (Team Readiness Assurance Test or tRAT). During thetRAT students discuss and come to a consensus on theirteam answers. Once the team has committed to an answerthe correct answer is revealed, providing them withimmediate feedback. This form of peer learning enablesmisconceptions to be clarified and knowledge gaps to befilled. Often the small group discussion leads to additionalquestions about the subject matter, which can then be dis-cussed classwide or posed to the teacher who provides thenecessary clarifications.In the third and final application exercise phase,students working in their teams are tasked with scenarios  – usually clinical problems or cases  –  that encourage them toapply what they have learned in the previous stages of TBL. These application exercises are undertaken in open book conditions and characterized by the  “ 4S ”  principle(Michaelsen et al. 2009). All student teams discuss the  “ same ”   problem, which must be  “ significant  ”   . Each team ’ s responserequires a  “ specific  ”    choice reflecting the team ‘ s consensus.During the second part of the application exercise phase,teams report their choices  “ simultaneously  ”   . Teams then par-ticipate in a classwide discussion that the teacher facilitates.At the end of the class discussion, the teacher may providean expert ’ s solution when necessary. In order to aid simultan-eous reporting, application exercises are often single bestanswer MCQs or short answer questions. TBL has similarities with problem-based learning (PBL),another widely implemented instructional approach inmedical education. Both approaches are based on con-structivist learning theory, involve active learning in smallgroups and make use of professionally relevant problems.However, TBL is distinct in its requirement for preclasspreparation, its sequence of in-class individual and teamactivities, its higher student-teacher ratio, and the way itcombines peer learning with immediate feedback andexpert clarification (Dolmans et al. 2015). Developing a new team-based learning curriculum  The Lee Kong Chian School of Medicine (LKCMedicine) isSingapore ’ s newest medical school. A partnership betweenNanyang Technological University, Singapore (NTUSingapore) and Imperial College London (Imperial), its firstcohort of students was admitted in 2013. The bespoke cur-riculum was developed jointly by faculty from both institu-tions, with some elements of the Imperial curriculumadapted and contextualized for Singapore and other ele-ments developed de novo. The program was planned as anintegrated systems-based curriculum, with a focus on clin-ical presentations throughout. In keeping with modern edu-cational practice, a decision was taken to move away fromstrict memorization of didactic materials and instead adoptprinciples of active learning with an emphasis on teamwork and application of knowledge (Partridge 2013). TBL wasestablished as the School ’ s principle classroom learning andteaching strategy across all years of the five-year program,dispensing with face-to-face lectures.In years 1 and 2 around 60% of curriculum time is dedi-cated to TBL, equating to around 140 TBL class days (twofull days of TBL plus two half days of preparation perweek). The focus of these TBL classes is the developmentof foundational scientific understanding, with the applica-tion exercises providing a means to contextualize the sci-ence to clinical presentations and clinical practice. In years3, 4 and 5, learning is primarily practice-based in clinicalsettings. Students do however regroup for campus teachingduring which TBL classes provide a means to link clinicalpresentations with medical decision-making (diagnostic rea-soning, management plans), potentially involving multipledisciplines. Across all year groups, cross-cutting coursessuch as professionalism, ethics, patient safety, pathologyand pharmacology are learned through TBL.An overview of the TBL process at LKCMedicine, withthe average time spent in each phase, is shown in Figure 1.Each TBL session is assigned approximately 4 to 6hours of scheduled time in the preparation phase, 1.5 to 2.5hours inthe readiness assurance phase and 2 to 3.5hours in theapplication phase. The process follows established guide-lines (Parmelee and Hudes 2012), although we have incor-porated an additional step at the end of the readinessassurance phase known as  “ burning questions ”  wherestudents are encouraged to submit questions with theintention of having their misunderstandings or uncertain-ties clarified. In keeping with TBL guidelines, students arein teams of six and team composition changes annually. The medical school is now in its fifth year of operation andstudent enrollment is growing year-on-year. The annual stu-dent intake has increased from 54 in 2013 to 120 currently. Key developments In planning delivery of the new TBL curriculum we werekeen to optimize the learning environment for the Figure 1.  Overview of TBL process at LKCMedicine. 2 P. RAJALINGAM ET AL.  students, mindful that TBL would be extensively practicedby faculty from different professional backgrounds, in dif-ferent courses and across all year groups. We were alsoaware that class sizes might increase to 200 or more. Howcould we ensure sustainability of the program and minim-ize the risk of pedagogical  “ drift ” ? To this end, we con-ceived three key approaches: (1) team-centric learningspaces (2) an integrated e-learning ecosystem customizedto support the TBL process and (3) teaching teams in everyclass. These are described below. Team centric learning spaces Many institutions planning a new curriculum for TBL (orother large group active learning method) are obliged toadapt existing conventional learning spaces, usually lecturetheaters. However, we had the opportunity, starting fromscratch, to design spaces bespoke for large TBL classes. Forthis reason, a decision was taken to forgo conventional lec-ture theaters and seminar rooms and instead opt for team-centric learning spaces, designed to optimize communica-tion both within and between teams. The architectural prin-ciples and human factors underpinning the design of activelearning spaces have been well documented (Oblinger andLippincott 2006). Although research specific to TBL is stillsomewhat limited, there is evidence that students ’  attitudestoward TBL improve with greater comfort and physical easeof communication (Espey 2008).One of the School ’ s learning studios is shown inFigure 2. It can accommodate up to 264 people (44 teamsof six individuals). The design has been conceptualize toenable small groups seated at round tables to engage inactive intra-team discussions. Discussions between teamsand with faculty are facilitated by microphones in the cen-ter of each table. Wifi connectivity allows students to wire-lessly project relevant information and resources to largehighly visible projection screens hung around the room.Despite its large size (620m 2 ), the circular design of the TBLLearning Studio and its dual tiered seating arrangement,enable students to see each other and have at least twoscreens from wherever they are seated in view. The value of a collaborative approach to designing phys-ical learning spaces and ensuring their alignment with cur-riculum is well recognized (Nordquist et al. 2016). Ourcommitment to TBL early in the design process and theeffective collaboration between faculty, academic leader-ship, facilities management and architects has transformedthe tradition role of a large space for instruction toone that is closely aligned with TBL, providing an engagingenvironment that is conducive to active, collabora-tive learning. Integrated eLearning ecosystem Aligned with the vision of a student-centric curriculum wewanted to establish an e-learning ecosystem that wouldprovide seamless support during all aspects of the studentlearning experience, including the spectrum of activitiesassociated with TBL (Gagnon et al. 2017). The LKCMedicineeLearning ecosystem was developed using a design-basedresearch approach (Reeves et al. 2005). A mobile app(iStudent) provides access to all timetabled activities,associated learning outcomes and resources. During thepreparation phase of TBL, students review the expectedlearning outcomes and retrieve the relevant learn-ing resources.Once in class, the sequence of activities is managed anddelivered digitally via a learning activity management sys-tem (iLAMS). This enables students to complete the TBLassessments (iRAT, tRAT and application exercises) andensures that correct responses are revealed to the studentteams at the appropriate time. In addition, following thereadiness assurance phase of TBL, students are encouragedto submit any remaining queries as  “ burning questions ” . Akey feature of iLAMS is the provision of real-time access byfaculty to student performance data, including individual(iRAT), team (tRAT, application exercises) and  “ burningquestions ” . These data are linked dynamically to a custom-ized dashboard. This is shown in Figure 3. The dashboard enables faculty to (i) instantly view stu-dent performance (individual and team), (ii) to identifyknowledge gaps that are most relevant to the class as awhole (iii) review burning questions arising from tRAT activ-ities and (iv) provide timely focused support during theclass. Outside the classroom, this expanding database of student performance data is monitored over time and usedin a number of ways (discussed further in Lessons Learned). Team teaching A key initiative in the early development of the School wasfaculty recruitment for the purpose of curriculum develop-ment and teaching. A willingness to engage with, and betrained in, TBL was a prerequisite for joining the School,and experts in TBL pedagogy were recruited to provide thenecessary expertise. How could we ensure that so many sci-entists and clinicians from a variety of different disciplineshad the necessary skills to facilitate their TBL sessions?Almost 20years ago, Harden and Crosby (2000) proposed atheoretical framework identifying 12 teaching roles of futuremedical teachers. These diverse roles included facilitator,information provider and resource developer. In the contextof TBL, the role of   “ facilitator ” ,  “ information provider ”  and “ resource developer ”  are commonly combined, despite thedisparate skill set required. At LKCMedicine, a decision wasmade that the role of TBL Facilitator would be separatedfrom that of   “ information provider ”  and  “ resource devel-oper ” , with the latter roles enacted by a Content Expert.Every class is co-taught by one or more Content Expertswho provide subject matter expertise, and a TBL Facilitatorwho manages productive student discussions and providesthe necessary pedagogical expertise. This approach ensuresthat while the class content is delivered and clarified by atleast one Content Expert, constructivist pedagogicalpractices (Fosnot and Stewart 2005) are put in place bythe Facilitator, as the  “ pedagogical process expert ” .Furthermore, a particular Content Expert may contribute toonly one or two TBL classes every year, whereas each TBLFacilitator is assigned a minimum of 15 TBL classes peryear. This ensures that the Facilitators are able to build arelationship with the students over time. MEDICAL TEACHER 3  Figure 2.  Team centric space design of the Learning Studio at LKCMedicine. Figure 3.  Dashboard used by faculty during TBL class, showing student performance data. 4 P. RAJALINGAM ET AL.
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