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Learner perception, expected competence, and satisfaction of team-based learning in Korean nursing students.


The purpose of this study was to describe learner perception, expected competence, and factors influencing satisfaction with team-based learning in a nursing course. Four-hour TBL sessions were given in a structured three-phase sequence for a cohort of 139 second-year nursing students. TBL was found to be an effective instructional strategy inducing team learning and self-directed learning. Nursing educators should improve TBL quality by focusing on the student team learning process.


Active Learning--Team-Based Learning--Nursing Education--Self-Directed Learning


In response to the alarming number of medical errors and issues of patient safety, many experts have recommended fundamental changes in education for health professionals (World Health Organization, 2011). Currently, health care providers typically train in professional silos that prevent interdisciplinary team practice. This approach is limited in its ability to equip graduates with the necessary knowledge, skills, and attitudes for working as part of a complex health care team (Lapkin, Levett-Jones, & Gilligan, 2013).

Team-based learning (TBL) is an active learning method developed to help students achieve course objectives while learning how to function in teams (Sisk, 2011). It is a form of collaborative learning that uses a specific sequence of individual work, group work, and immediate feedback to create a motivational framework in which students increasingly hold one another accountable for coming to class prepared and contributing to the discussion (Michaelsen & Sweet, 2008).

A systematic review of 17 TBL studies revealed three major outcomes: higher student satisfaction, enhanced engagement, and better examination scores. Thus, students are generally satisfied with TBL as an alternative and active learning method (Sisk, 2011). Some researchers in nursing education have reported that nursing students who received TBL reported more in-class participation (Clark, Nguyen, Bray, & Levine, 2008) or higher levels of engagement (Mennenga, 2010) than nursing students who had not received TBL. Cheng, Liou, Tsai, and Chang (2013) reported that TBL significantly influenced students' learning outcomes in a maternal-child nursing course.

According to the conceptual model for TBL, factors such as individual and team characteristics, context, and teacher decisions influence learner engagement. Several learning outcomes result from learner engagement with course content and within teams: greater depth of knowledge, more developed cognitive structures, and better problem-solving, team communication, and leadership skills (Haidet, Schneider, & Onady, 2008). Factors associated with changes in the use of TBL were faculty, students, administration/curriculum, and courses (Thompson, Schneider, Haidet, Levine, et al., 2007). Moreover, the development and availability of expertise, as well as buy-in from faculty, prove vital in implementation (Thompson, Schneider, Haidet, Perkowski, & Richards, 2007).

Identifying students' perceptions about the TBL learning process, as well as the factors that affect student satisfaction, can help nurse educators plan suitable approaches when adapting TBL to nursing education. Although TBL has been reported to be generally effective, there is little evidence of its precise impact in nursing education. The purposes of this study were to assess the perception, expected competence, and satisfaction of learners in a TBL program and to identify which factors influence overall satisfaction.


Conceptual Model

Greater degrees of and higher quality engagement with both content and other learners are expected to favorably affect a variety of students' learning outcomes, such as knowledge, skills, and attitudes. The key concepts adopted from the original conceptual model for TBL (Haidet et al., 2008) are as follows: learner perception and satisfaction (learner engagement with course content and within teams) and expected competence (learning outcomes).


The present study had a descriptive survey design. Ethical approval was granted by the ethics committee of the college of nursing in the Republic of Korea where the study took place.


All 147 students from a three-year nursing associate program who were enrolled in a medical-surgical nursing course participated in the study. Participants were selected from a convenience sample of second-year students in the spring 2010 semester. Data from 139 (95 percent) nursing students were analyzed after eight incomplete questionnaires were excluded (5 percent). Eighty-eight percent of the participants were women; their ages ranged from 19 to 43 years (M = 21.3, SD = 3.38).

Participants were informed that they could refuse to participate or withdraw from the survey at any time without penalty. All participants signed an informed consent form.


Two two-hour TBL sessions were scheduled into a four-credit integrated nursing course. The course consisted of 2.5 credits of lecture (approximately 32.5 hours), 1 credit of small-group sessions (approximately 13 hours), and 0.5 credit of simulation (approximately 13 hours). TBL was implemented in 4 hours of the small-group sessions.

The course consisted of nursing care for patients with gastrointestinal and genitourinary problems. The content of the TBL course focused on nursing care for patients with renal failure. An introduction to TBL took place on the first day of class.

The nursing students were assigned to 25 teams of five or six students by random selection, using student numbers. Four faculty members participated in this course as tutors, with five or six teams meeting in the discussion room at one time. The major principles of TBL were adopted for this study, and three sequence sessions were structured for implementation: preparation, readiness assurance, and application (Michaelsen & Sweet, 2008).

PREPARATION SESSION During the pre-class preparation session, students completed readings on the unit topic: pathophysiology, nursing assessment, and management of patients with renal failure.

READINESS ASSURANCE SESSION Students took short multiple-choice quizzes about the preparatory material and were provided immediate feedback to ensure they were ready to engage in the next step of learning. Two types of readiness assurance tests were administered: the Individual Readiness Assurance Test (IRAT) and the Group Readiness Assurance Test (GRAT). Test items were prepared by the authors and based on course textbooks and Korean review books for the licensure examination for registered nurses. The items were meant to assess students' basic understanding of the facts and concepts included in the preparatory material.

The IRAT was implemented during the first week. It included 12 multiple-choice questions to be completed within 25 minutes. Test items were scored as 1 (true response) or 0 (false response) for a total maximum score of 12.

The GRAT was completed by each team using the same IRAT items, also within a 25-minute time limit. After completion, a facilitator prompted the teams to simultaneously hold up a card representing each answer. Discrepancies were addressed by asking the teams to defend their answers. If all teams displayed the same answer, the facilitator asked if there were any lingering questions about the item or related content. This discussion lasted about 50 minutes.

APPLICATION SESSION The third phase of TBL is to apply course concepts through activities to enhance student understanding of the content and increase group cohesion. Students work in class in groups to solve challenging problems created by the faculty member (Mennenga, 2010). In the second week, an application session was delivered using a real-life case scenario of a patient with chronic renal failure. Each team reviewed the patient scenario and discussed nursing care assessment and implementation. After completing the team discussion, the teams presented their nursing care plan, shared information through discussion, and received feedback from other teams and faculty. The application session lasted 100 minutes.

Data Collection/Measurement

One week after the final TBL session, students completed the TBL Course Operation and Evaluation Tool and the Overall Satisfaction with TBL Questionnaires (Cho et ah, 2010). Items on the Operation and Evaluation Tool are rated on a seven-point Likert-type scale with scores ranging from 1 (strongly disagree) to 7 (strongly agree). Higher scores indicate more positive responses. Content validity for this six-factor tool was verified by two experts. Five of the six factors are: Team Learning, five items; Faculty Feedback, four items; Readiness Assurance Test, three items; Self-Directed Learning, five items; and Peer Evaluation, three items. The sixth factor, Expected Competence, was measured using the following item: "The TBL experience can improve the following competencies: perceived ability in self-directed learning, communication and collaboration, positive experiences of teamwork, enhancement of academic achievement, and acquisition of practical knowledge." Cronbach's alphas for the scale have been reported as .85 to .95 (Cho et al.); for this study, Cronbach's alpha was .93.

Overall Satisfaction with TBL was evaluated with two items: satisfaction with TBL compared with didactic lectures and general satisfaction with the TBL process. A seven-point Likert-type scale, with scores ranging from 1 (strongly disagree) to 7 (strongly agree), was used for these items.

Data Analysis

All statistical analyses were performed using SPSS version 20.0. Descriptive statistics were performed to describe general characteristics and study variables. Cross-sectional relationships between variables were explored using Pearson r correlations. Multiple regression analysis with enter methods was performed using the five learner-perception variables to identify factors influencing overall satisfaction with TBL.


Learner Perception, Expected Competence, Overall Satisfaction

On the seven-point scale, the highest mean learner perception score was 5.17 [+ or -] 0.85 for the Team Learning subscale; the lowest was 3.84 [+ or -] 1.00 for the Peer Evaluation subscale. The highest rated expected competence from participating in the TBL sessions was Self-Directed Learning (5.15 [+ or -] 1.31). Approximately 33 percent of nursing students were satisfied with TBL compared with didactic lecture, and 32 percent were satisfied with the TBL learning process.

Relationship Between IRAT and GRAT Scores with Other Study Variables

There was a significant relationship between IRAT and GRAT scores (r = .543, p < .001). There were no significant relationships found between IRAT or GRAT scores and learner perception, expected competencies, or overall satisfaction. Finally, no significant differences in study variables by student age were found.

Learner Perception Factors Influencing Overall Satisfaction

The learner perception factors that significantly influenced overall satisfaction with TBL were Team Learning, Self-Directed Learning, and Faculty Feedback (F = 25.94, p < .001); these three variables accounted for 47.5 percent of variance in overall satisfaction. The Readiness Assurance Test and Peer Evaluation did not affect overall satisfaction. Team Learning, the best predictor, explained 39.2 percent of the variance in overall satisfaction.


Findings from this study showed that, overall, students were not strongly satisfied with TBL. This result is consistent with the literature (Clark et ah, 2008; Lubeck, Tschetter, & Mennenga, 2013; Mennenga, 2010). In the case of this study, it is possible that since this was the students' first exposure to TBL, the process may have been experienced as intense and challenging. Students were accustomed to the traditional lecture format, which inhibits student engagement and does not offer opportunities to apply information (Lubeck et al.).

Nursing competencies encompass clinical biomedical science, general clinical skills, critical thinking, communication and teamwork, ethics, caring, lifelong learning, and accountability (Hsu & Hsieh, 2013). The TBL design requires self-directed learning, learner-to-learner interactions, and teamwork, which are all part of professional competence. For the current study, the Team Learning and Faculty Feedback factors received the two highest scores, and the learner perception factors that influenced overall satisfaction with TBL were Team Learning, Self-Directed Learning, and Faculty Feedback. This result concurs with previous findings for health sciences education, where factors with the strongest influence on the implementation of TBL were buy-in by faculty, resources, and course characteristics (Thompson, Schneider, Haidet, Perkowski, et al., 2007).

According to the conceptual model for TBL, factors such as individual and team characteristics, context, and teacher decisions influence learner engagement. Furthermore, greater degrees of and higher quality engagement with both content and other learners are expected to favorably affect a variety of learning outcomes, such as knowledge, skills, and attitudes (Haidet et al., 2008). Therefore, to improve the quality of learner engagement, nurse educators should consider a range of factors, including team learning, self-directed learning, and faculty feedback, when designing and implementing TBL courses.


This initial attempt to incorporate TBL into an undergraduate nursing course on nursing care for patients with renal failure was a generally positive experience for the students. The results of this study support findings that TBL is an effective instructional strategy, with beneficial impact on expected competence and overall satisfaction. Active adoption of TBL instructional strategies in nursing education is needed, but to improve student satisfaction, the predictors found in this study should be considered when designing and implementing TBL courses.

One limitation of this study was the relatively short educational intervention time, which may have led to bias, positive or negative. Furthermore, the data represent students in a single academic year, at a single educational site. Further study is needed to assess the longitudinal learning outcomes of TBL, as well as the benefit of longer intervention periods. Future studies should consider a series of factors, including individual and team characteristics, context, and teacher decisions in their assessments of the efficacy of TBL in accordance with the conceptual model.

doi: 10.5480/13-1200


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Young Sook Roh, PhD, RN, is an associate professor, Chung-Ang University, Red Cross College of Nursing, Seoul, Republic of Korea. Suk Jeong Lee, PhD, RN, is an associate professor, Chung-Ang University, Red Cross College of Nursing, Seoul, Republic of Korea. Dongwon Choi, PhD, RN, is an assistant professor, Incheon Catholic University, College of Nursing, Incheon, Republic of Korea. For more information, write to Dr. Choi at
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Author:Roh, Young Sook; Lee, Suk Jeong; Choi, Dongwon
Publication:Nursing Education Perspectives
Article Type:Report
Geographic Code:9SOUT
Date:Mar 1, 2015
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