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Table of Contents
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 198-205

What is team-based learning, and how is it used in nursing?

University of Alabama, Birmingham, AL, USA

Date of Submission30-Nov-2020
Date of Decision03-Jan-2021
Date of Acceptance05-Jan-2021
Date of Web Publication19-Feb-2021

Correspondence Address:
Prof. Annetta Dolowitz
University of Alabama, Birmingham, AL
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCN.IJCN_8_21

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Team-based learning (TBL™) is an active learning and teaching strategy where students have an active role in their learning. It is a method where the instructor facilitates learning, not lecture from the front of the room. TBL™ is also a very structured teaching strategy based on cognitive learning theory. Team formation, readiness assurance process, application activities and peer evaluation are the four pillars of TBL™. TBL™ has become popular and is a preferred teaching method in nursing education in many institutions. The aim of this article is to introduce the process of TBL™ and discuss its use in nursing.

Keywords: Active learning, collaborative learning, nursing, team-based learning

How to cite this article:
Dolowitz A. What is team-based learning, and how is it used in nursing?. Indian J Cont Nsg Edn 2020;21:198-205

How to cite this URL:
Dolowitz A. What is team-based learning, and how is it used in nursing?. Indian J Cont Nsg Edn [serial online] 2020 [cited 2021 Oct 18];21:198-205. Available from: https://www.ijcne.org/text.asp?2020/21/2/198/309862

  Introduction Top

Team-Based Learning™ (TBL™) is an active, collaborative method of small group teaching-learning method which is used for large classes and was introduced by Larry Michaelson, a Professor of management at the University of Missouri, USA. In the early 1980s, Michaelsen found it necessary to change the way he was teaching when his classes grew from 40 learners to 120. He had been teaching in small teams with case studies and in-depth discussions until then. With the tripling of his class size, Michaelsen could no longer achieve the outcomes he had with a smaller class: High student engagement and critical thinking.[1] Due to these changes, Michaelsen turned to cognitive learning strategies and theories. Cognitive learning strategies improve learners' ability to process information more deeply and enhance learners to transfer and apply learned concepts to practical situations.[2] Cognitive learning fits with active learning styles[3] and therefore provided a firm platform for TBL™ methods.

Michaelson's first change was 'flipping' the classroom. TBL™ is based on the flipped classroom method where the students engage in self-paced learning of class material assigned to them before class, outside the classroom and engage in the active application of learned concepts in the classroom with their peers and teacher.[4],[5] Another poignant emphasis in TBL™ is on the teacher becoming a facilitator rather than information provider, a shift from 'sage on stage' to 'guide from the side.'[6],[7] Michaelsen is considered to be the 'father' of TBL™ and is a founding member of the Team-Based Learning Collaborative. TBL™ is considered as an active form of teaching and an approved teaching strategy by both the medical and nursing accreditation bodies in the United States (US) and now is used as part of formal education in medical and nursing schools throughout the world.

  The Four Pillars of TBL™ Top

Pillar 1: Team formation

During the initial experimenting, Michaelson recognised that the learners were not only giving each other 'lectures' he would have done on the material, he also observed that learners were developing into social units in their teams. Upon realising this, he decided that he would keep the same learners on their teams for the semester. The ideal team size is 5–7 in a face to face course.

What is essential to know when forming teams is that this is a strategically random process. The random process assures that the 'wealth' of knowledge and skills which the students have is evenly distributed amongst the teams. For example, in a Nursing Management course for Masters level students which engages in TBL™, it will be good to have students with different years of nursing experience, from different specialties and different institutions to be mixed in the teams. This random choice brings not only richness to the learning that happens in every team but also assures the even distribution of the same experience and expertise in class. As students form permanent teams for the semester or for the course, the communication and trust among the students become stronger facilitating better learning experiences.[8]

Pillar 2: Readiness assurance process

The second pillar in the TBL™, the Readiness Assurance Process (RAP), involves ensuring that the students exhibit their true readiness to apply the concepts that they have learned. With flipping as a pedagogical philosophy, students are expected to engage in pre-class preparation as an initial step in TBL™. Teacher provides appropriate course material in the form of lecture notes, articles, book chapters, videos, online resources, etc. The pre-class resource material needs to include only introductory concepts that can be understood by students and those that they can apply in problem-solving in the classroom.[9] The challenge that Michaelson initially came across was to ensure that the students were truly prepared before coming to class [Figure 1].
Figure 1: Readiness Assurance Process

Click here to view

One thing he had learned over his years of teaching was that learners always seem to read the materials before a test. Applying this observation to TBL™, the class started with a test called the individual readiness assurance test (iRAT). In the iRAT students had to complete the test independently and hand over the test to the teacher. Another key objective for Michaelsen was building team communication skills. Michaelsen decided that the best way to achieve this was to have the team take the same quiz (MCQ format) together which is called the team readiness assurance test (tRAT).[1] In the tRAT, students have the opportunity to discuss with each other in their teams and negotiate on choosing the correct answers on the scratch cards until they get the right answer. The t RAT is graded with a scoring system which makes the learning interesting and competitive between the teams as the obtained scores of the teams are stimulating to perform better in teams. The tRAT activity augments individual learning. A mini-lecture may be provided as a conclusion of RAP to clarify concepts that are difficult for students.[8]

Pillar 3: Application activities

The third pillar in TBL™, the application activities, is the core of in-class learning. The idea behind the application principle is to 'force' learners to make decisions about a specific problem, much like they will in the workplace. Application exercises allow students to rehearse making critical decisions. When done well, this process also helps learners develop and refine their critical thinking skills and apply what they have learned to significant problems and engage in problem-solving as a team.[1] Michaelsen and Sweet[1] coined the 4-S activity process for the application of the concepts that the students had learned.

  • Significant problem
  • Same problem
  • Specific choice
  • Simultaneous report.

When an activity is designed for the application, the problem that is selected should be one that is relevant to their practice. In other words, the problem is significant and would matter in the specific discipline/course. The specific choices should be concepts that learners need to use to make their decisions. For a less rigorous application, students can be provided the answer options; for a more advanced exercise, students are encouraged to generate the answer using course concepts to support their answer. It is essential that each team takes one position and explains why they believe it was the best answer. Each team should be addressing the same problem. The idea is for learners to pay attention to how other teams have answered the problem, which will increase inter-team discussion. Finally, the teams must simultaneously report their answers. This prevents teams from just agreeing with other teams or changing their minds once they see other teams' decisions. Many learning experiences take place during the simultaneous reporting because the facilitator and the teams get to see when teams have the minority answer, and yet it may be the best answer given.[1] The vital point for teachers to note is to have well-planned and structured application exercises to make it a meaningful learning activity.

Pillar 4: Peer evaluation

Engaging in group work can bring forth issue of work not being fairly distributed or having some students not prepared adequately for class and not doing their fair share of the work for the team, denoted by a term called 'freeloading.' Michaelsen decided to have the teams hold each other accountable by allowing them to help determine the weighting of teamwork, individual work, and individual contribution to the teamwork. In addition to the student's inputs, Michaelsen began including peer evaluation.[1] Thus, the fourth major component of TBL™ was created as peer evaluation.

Teams can and sometimes will 'game' the system meaning, they will collaborate to make sure they give each other all the same ratings to look good. At other times teams may focus their blame on one or two members. The teacher should explain teams that 'gaming' is unethical and unacceptable, and the evaluation should be fair, based on true participation and contribution. In case of controversies, the teacher needs to address the issue immediately. The other key in the evaluation is to have the teams provide written feedback to justify their scores.

In addition, questions arise concerning team cohesion and performance. Over the years, as more faculty, lecturers, and instructors have begun to implement TBL™, the presence of a 'difficult team' or a 'difficult student' has been reported. A strategy that has been developed and shared, especially at the annual TBLC conferences, is the concept of a team charter or team contract. The basic components for a team contract include the contract information for team members, the team roles and tasks, and who will be filling those roles. If and when issues/conflicts arise within teams, the team contract is revisited for clarification and revised if needed.

In summary, there are four major parts to TBL™. The teacher begins by strategically creating teams, and 'flip' how the materials are presented to the students. This means they come to class having read or watched the materials needed for the unit. The teacher begins the class holding the learners accountable for these materials by giving them a quiz or iRAT. These questions are to help ensure that the learners are ready to apply the unit's main concepts in the application exercises. Then, the team takes the same quiz again (tRAT). After the quiz is completed, the teacher will know how best to tailor any needed lecture to clarify questions that were missed. Once all clarifications have been made, the remaining time in this unit (whether it is a week or 2 weeks) is spent on applying the information in exercises created following the 4-S design. This process is known as a TBL™ Cycle that would be repeated depending on the number of units or modules in the course. Finally, the students complete both a midterm evaluation and an end of term evaluation. These evaluations are for each member of the team and include a self-evaluation.

  Team Based Learning-Use in Nursing Top

In the US., there is an emphasis on using active learning methods in the medical and nursing curriculum.[10] Simulation and TBL™ are two teaching methods that meet the active learning standards of accreditation in nursing in the US and internationally. Kang et al.[11] augmented their newborn nursing care simulation course with TBL™ as did Najjar[12] who used TBL™ to supplement the high-fidelity simulation in an undergraduate paediatric nursing course. Both sets of researchers found that test scores and academic achievement were higher in the course that combined both simulation and TBL™ methods.[11],[12] Kang et al.[11] found that not only were scores higher for participants, but scores were also significantly improved for lower-achieving learners. Oldland and Currey[13] found that learning outcomes were better achieved in the groups where both strategies were combined. Oldland and Currey[13] site several studies of how nursing education outcomes are better met using TBL™. A major reason for this is based on the emphasis on recalling knowledge of the course, tested during the RAP, and applying it to make critical decisions during the application exercises. Not only are teams applying the concepts but they are also expected to identify and defend why their answers are better or not as good as another team's responses.

Other researchers wanted to explore how using TBL™ would influence core competencies and learners' perceptions of classroom climate in nursing. Lee[14] explored the core competencies of nursing students who were participating in TBL™ courses versus traditional lecture-based courses. The two groups were equivalent in size. Both groups attended 6 h of classes: Two hours a week for 3 weeks. Both groups were given a pre-test, then the 'intervention,' and a post-test to measure their core competencies. The group participating in TBL™, scored significantly higher in clinical competence skills, communication competence, and self-leadership. All these skills are essential qualities for nurses to possess in critical care situations. Whereas Lee[14] explored core competencies, Koohestani and Baghcheghi[15] assessed how TBL™ impacts the learners' environment, the classroom. They wanted to determine the effects of TBL™ techniques on students' perceptions of the psycho-social climate of the classroom. They divided the course in half and the first eight sessions were conducted in traditional lecture style, and the remaining eight sessions were conducted using TBL™. The researchers compared the students' perceptions of each part of the divided course and the results indicated that there was a significant difference between the two methods of teaching. Students found TBL™ provided more opportunity for participation, which provided evidence that TBL™ method improves students' perception of the psycho-social climate in the classroom.

In Fatmi and Oswald's[16] review of the literature, they found that there are limitations as well as benefits to TBL. They discovered that learner's knowledge increased with the use of TBL™, and that learners had mixed feelings about TBL™. Fatmi and Oswald[16] suggest that in part, the learners' mixed responses may have more to do with the increased student workload. TBL™ requires that learners be active in their learning. Learners are held accountable to come prepared to class and 'teach' each other during the RAP. Fatmi and Oswald[16] also note that a culture shift is required in courses and the curriculum, one that emphasises peer assessment and accountability.

One main challenge, and possible limitation in TBL, is the time commitment. This method is very rewarding when the structure of TBL™, is followed but will take much more time than a traditional lecture course. In the beginning, teachers need to be willing to commit a large amount of time thinking about what the learners need to do that demonstrates that they have met the learning objectives. Activities have to be thoughtfully created so that learners can demonstrate they can perform this skill or competency. Once activities are created for learners teachers must then find the materials that the learners will need to read or watch to prepare them to be able to engage in the prepared activities. The RAT quizzes are then created based on the selected materials to ensure that learners have the basic or foundational knowledge to engage in the activities that have been created for them to demonstrate that they have met the course objectives. It is important to notice that in TBL™ method, the teacher is designing the course in reverse.

  Conclusion Top

As there is strong evidence on the effect of TBL™ on positive learning outcomes, TBL™ can and should be explored as a teaching strategy in nursing in all institutions. With meaningful application exercises as principal classroom activity, nurse faculty have better opportunities to engage students in critical thinking and problem-solving scenarios and facilitate transfer and application of knowledge in their clinical practice which is the essence of nursing education.

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Conflicts of interest

There are no conflicts of interest.

CE Test No. - 39 Questions

  Team Based Learning Top

  1. When adopting TBL™ as a teaching strategy in your course, what should your focus be as you design your course?

    1. What the learner knows.
    2. What the learner learners.
    3. What the learner can do.
    4. What the learner can recall.

  2. When creating your courses, when do you create your iRAT/tRAT (quiz) for each unit (module)?

    1. At the beginning of designing your unit or module.
    2. In the middle of your unit or module.
    3. Before you select your course materials.
    4. After you designed the unit or module.

  3. True or False: TBL™ is a structured teaching strategy?

    1. True
    2. False

  4. True or False: Transitioning to TBL™ will use the equivalent amount of preparation time as a traditional lecture course?

    1. True
    2. False

  5. What is the order of the TBL™ cycle?

    1. Team Formation, RAP, 4-S Activities
    2. Pre-reading Materials, RAP, 4-S Activities
    3. RAP, Pre-reading Materials, Peer Evaluations, 4-S Activities
    4. Team Contract, RAP, 4-S Activities, Peer Evaluations

  6. What are the four pillars or components of TBL™?

    1. Pre-reading Materials, RAP, 4-S Activities, Peer Evaluations
    2. Team Formation, RAP, 4-S Activities, Peer Evaluations
    3. RAP, Pre-reading Materials, Peer Evaluations, 4-S Activities
    4. Team Contract, RAP, 4-S Activities, Peer Evaluation

  7. What is the BIGGEST limitation of implementing TBL™ according to the findings of Fatmi and Oswald's (2013)?

    1. The amount of time to create a team contract.
    2. Learners mixed reviews of a TBL™ course.
    3. Inconclusive results of learning outcomes.
    4. Learners negative view of the learning climate.

  8. What is one of the critical skills Oldland and Currey's (2020) brief focus on the literature stated TBL™ developed?

    1. Team cohesion
    2. Individual performance
    3. Increased knowledge
    4. Critical decision making

  9. In the RAP pillar, what is NOT typically of traditional courses?

    1. Conducting a 4-S activity.
    2. Creating a team contract.
    3. Giving a team a quiz.
    4. Giving a peer evaluation.

  10. According to what you have read, where is TBL™ used to teach in nursing schools?

    1. Asia
    2. Africa
    3. Europe
    4. All of the a'bove

  11. What are the four “S's” of the 4-S design?

    1. Significant problem, Specific choice, Same problem, Simultaneous reporting
    2. Specific selection, Similar problem, Synchronized reporting, Same format
    3. Specific, Similar, Simultaneous, Same
    4. Significant, Synchronized, Substantial, Specific

  12. What is the purpose of the RAP (iRATs and tRATs)?

    1. Students will have the key knowledge to engage in the 4-S activity.
    2. To prepare students to pass a comprehensive exam.
    3. To make sure students have read the materials before coming to class.
    4. To make the team more successful in learning outcomes.

  13. What is one of the tools you can use to help manage your teams?

    1. randomization of teams
    2. team contracts
    3. iRAT's
    4. pre-readings

  14. What is the ideal size for your teams, according to Michaelsen?

    1. 3-5
    2. 4-6
    3. 5-7
    4. 7-9

  15. What did Lee (2018) discover evaluating nursing student's core competences comparing outcomes from the use of both lecture style and TBL™ teaching methods?

    1. Neither method lead to significantly higher results in core competencies
    2. That both methods of teaching led to significantly higher competencies in communication and clinical skills. That TBL™ teaching methods significantly higher core competencies in communication and clinical skills.
    3. That lecture style teaching methods led to significantly higher competencies in communication and clinical skills.
    4. That lecture style teaching methods led to significantly higher competencies in communication and clinical skills

  16. The “Flipped” method used in TBL™ denotes

    1. Teacher prepares the lessons prior to class and gives a mini lecture in class
    2. Students reads and prepares outside class and applies knowledge in class
    3. Students are given team tests and individual tests in class
    4. A quiz is given before the lecture is delivered by the teacher

  17. When should peer evaluations be given according to this pillar?

    1. At the middle of the course.
    2. After each module or unit.
    3. At the beginning of the course and at the end of the course.
    4. At the middle of the course and the end of the course

  18. When should students be prepared for the class?

    1. When it is time to present a project.
    2. When it is time to take a test.
    3. When it is time to participate in a simulation.
    4. When class begins.

  19. Why are the application exercises so critical in the TBL™ cycle?

    1. Because it allows students to simultaneously explore different problems they will encounter on the job.
    2. Because students are able to see how other teams respond and change their answers, so they are not in the minority.
    3. Because it follows the RAP process, where students show you what they know.
    4. Because it requires learners to critical think and support only one decision.

  20. How should you form teams?

    1. By letting the students form the teams.
    2. By randomly placing students on teams.
    3. By spreading the “wealth.”
    4. After a few class sessions.

Answers for CE test no 38: Corona Virus Disease 2019

1. d

2. a

3. a

4. a

5. a

6. c

7. b

8. a

9. a

10. a

11. b

12. c

13. c

14. d

15. a

16. b

17. c

18. c

19. c

20. b

CE Test No:39

What is Team-Based Learning, and how is it Used in Nursing?

Select the best answer and shade the circle against the suitable alphabet in the answer form provided.


Evaluation: Listed below are statements about the CNE on 'What is Team-Based Learning, and how is it Used in Nursing?'. Please circle the number that best indicates your response.

NAME: ______________________________________________

PRESENT MAILING ADDRESS: ________________________________________



Cut out or photocopy this form, fill and mail before June 31, 2021 to The Editor-in- Chief, IJCEN, College of Nursing, CMC, Vellore- 632004, along with a demand draft of Rs. 100/- (One hundred only), drawn in favour of CMC, Vellore Association. A Certificate will be awarded to all the participants and a merit certificate to those who secure marks 80% and above. Participants who secure 100% will be awarded one issue free subscription of IJCNE.

  References Top

Sweet M, Michaelsen LK. Team-based learning in the social sciences and humanities: Group work that works to generate critical thinking and engagement. Virginia: Stylus Publishing, LLC; 2012.  Back to cited text no. 1
Kumari M. Learning Theories -Cognitive Learning Theories. 2020 Available from: https://www.academia.edu/12133763/. [Last accessed on 2020 Dec 15].  Back to cited text no. 2
Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Willingham DT. Improving students' learning with effective learning techniques: Promising directions from cognitive and educational psychology. Psychol Sci Public Interest 2013;14:4-58.  Back to cited text no. 3
McLaughlin JE, Roth MT, Glatt DM, Gharkholonarehe N, Davidson CA, Griffin LM, et al. The flipped classroom: A course redesign to foster learning and engagement in a health professions school. Acad Med 2014;89:236-43.  Back to cited text no. 4
University of Adelaide. The Flipped Classroom. 2018 Available from: https://www.adelaide.edu.au/flipped-classroom/about/. [Last accessed on 2020 Dec 15].  Back to cited text no. 5
Morrison CD. From 'sage on the stage'to 'guide on the side': A good start. Int J Scholarsh Teach Learn 2014;8:1-15.  Back to cited text no. 6
Burgess A, Haq I, Bleasel J, Roberts C, Garsia R, Randal N, et al. Team-based learning (TBL): A community of practice. BMC Med Educ 2019;19:369.  Back to cited text no. 7
Michaelsen LK, Sweet M, Parmelee DX, editors. Team-Based Learning: Small Group Learning's Next Big Step: New Directions for Teaching and Learning, Number 116. California: John Wiley & Sons; 2011.  Back to cited text no. 8
The University of British Columbia. 2014 Available from: https://cdn.ymaws.com/teambasedlearning.site-ym.com/resource/resmgr/Docs/TBL-handout_February_2014_le.pdf. [Last accessed on 2020 Dec 15].  Back to cited text no. 9
Kang KA, Kim SJ, Oh J, Kim S, Lee MN. Effectiveness of simulation with team-based learning in newborn nursing care. Nursing Health Sci 2016;18:262-9.  Back to cited text no. 11
Al Najjar H. Effectiveness of team-based learning with high fidelity simulation in an undergraduate pediatric course for nurses. Saudi J Health Sci 2020;9:12.  Back to cited text no. 12
  [Full text]  
Oldland E, Currey J. Team-based learning promotes high level student engagement. Aust Nurs Midwifery J 2020;26:48.  Back to cited text no. 13
Lee KE. Effects of team-based learning on the core competencies of nursing students: A quasi-experimental study. J Nurs Res 2018;26:88-96.  Back to cited text no. 14
Koohestani HR, Baghcheghi N. The effects of team-based learning techniques on nursing students' perception of the psycho-social climate of the classroom. Med J Islam Repub Iran 2016;30:437.  Back to cited text no. 15
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:e1608-24.  Back to cited text no. 16


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