Accepted Manuscript Developing Professional Attributes In Critical Care Nurses Using Team-Based Learning Associate Professor Judy Currey, RN, BN(Hons), CritCareCert, GCertHigherEd, GCertSc(App Stats), PhD, Associate Professor in Nursing, Dr Paula Eustace, RN, BN, GradDipCritCareNsg, GCertHigherEd, PhD, Research Fellow, Ms Elizabeth Oldland, RN, GDipAdvNurs (Critical Care), GCertHigherEd, MNursPrac, Lecturer, Mr David Glanville, RN, BN, GDipNsg(CritCare), MN, Clinical Nurse Educator, Dr Ian Story, PhD, Head, Faculty of Health Academic Development Unit PII:
S1471-5953(15)00012-8
DOI:
10.1016/j.nepr.2015.01.011
Reference:
YNEPR 1952
To appear in:
Nurse Education in Practice
Received Date: 14 November 2013 Accepted Date: 18 January 2015
Please cite this article as: Currey, J., Eustace, P., Oldland, E., Glanville, D., Story, I., Developing Professional Attributes In Critical Care Nurses Using Team-Based Learning, Nurse Education in Practice (2015), doi: 10.1016/j.nepr.2015.01.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE: DEVELOPING PROFESSIONAL ATTRIBUTES IN CRITICAL CARE NURSES USING TEAM-BASED LEARNING
AUTHORS: Judy Currey, Paula Eustace, Elizabeth Oldland, David Glanville, Ian Story Associate Professor Judy Currey RN, BN(Hons), CritCareCert, GCertHigherEd, GCertSc(App Stats), PhD Associate Professor in Nursing Deakin University School of Nursing and Midwifery, Deakin University, 221 Burwood Hwy, Burwood, Victoria, Australia, 3125
[email protected] 92446122 92446159
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Name: Qualifications: Position: Institution or Affiliation: Address:
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Email: Phone: Fax:
Dr Paula Eustace RN, BN, GradDipCritCareNsg, GCertHigherEd, PhD Research Fellow Deakin University* *at time of study School of Nursing and Midwifery, Deakin University, 221 Burwood Hwy, Burwood, Victoria, Australia, 3125
Name: Qualifications: Position: Institution or Affiliation: Address:
Ms Elizabeth Oldland RN, GDipAdvNurs (Critical Care), GCertHigherEd, MNursPrac Lecturer Deakin University School of Nursing and Midwifery, Deakin University, 221 Burwood Hwy, Burwood, Victoria, Australia, 3125
[email protected] TE D
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Email:
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Name: Qualifications: Position: Institution or Affiliation: Address:
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Name: Qualifications: Position: Institution or Affiliation: Address: Email:
Name: Qualifications: Position: Institution or Affiliation: Address: Email:
Mr David Glanville RN, BN, GDipNsg(CritCare), MN Clinical Nurse Educator Deakin University & Epworth Healthcare School of Nursing and Midwifery, Deakin University, 221 Burwood Hwy, Burwood, Victoria, Australia, 3125
[email protected] Dr Ian Story PhD Head, Faculty of Health Academic Development Unit Deakin University Faculty of Health, Deakin University, 221 Burwood Hwy, Burwood, Victoria, Australia, 3125
[email protected] ACCEPTED MANUSCRIPT Acknowledgements and funding: This study was generously funded by a Strategic Teaching and Learning Grant by Deakin University. Conflict of interest statement: No conflict of interest has been declared by the authors Word count (abstract): 205
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Word count (manuscript and citations): 4602
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Keywords: Team-Based Learning, nursing education, critical care, critical thinking
ACCEPTED MANUSCRIPT Abstract Australian nurses prepare for specialty practice by undertaking postgraduate theoretical and clinical education in partnership models between universities and hospitals. In our global healthcare system, nurses require advanced critical thinking and strong communication skills
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to provide safe, high quality patient care. Yet, few education programs focus on developing these skills. Team-Based Learning (TBL) is a specific educational strategy that encourages and rewards students to think critically and solve clinical problems individually and in teams. The aim of this study was to investigate critical care nursing students’ perceptions and
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experiences of TBL after it was introduced into the second half of their postgraduate specialty course.
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Following Ethics Committee approval, thirty-two students were invited to participate in an extended response questionnaire on their perceptions of TBL as part of a larger study. Data were analyzed thematically.
Postgraduate students perceived their professional growth was accelerated due to the skills
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and knowledge acquired through TBL. Four themes underpinned the development and accelerated acquisition of specialty nurse attributes due to TBL: Engagement, Learning Effectiveness, Critical Thinking, and Motivation to Participate.
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Team-Based Learning offered deep and satisfying learning experiences for students. The early acquisition of advanced critical thinking, teamwork and communication skills, and
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specialty practice knowledge empowered nurses to provide safe patient care with confidence.
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ACCEPTED MANUSCRIPT Introduction The delivery of quality clinical care to patients rarely depends solely on a clinician practicing in isolation. Individual skills and experience are critically important, but the best outcomes are achieved when skilled clinicians work cooperatively within an effective healthcare team. A well-functioning team marked by good communication and teamwork contributes qualitatively and empirically to better
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informed clinical judgements, practices and decision-making (Australian Commission on Safety and Quality in Health Care, 2010a, 2011).
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Yet, it is individual skills and knowledge and not team-based skills that are principally recognized and rewarded as hallmarks of clinical expertise (Benner, 1984; McHugh, 2010). Postgraduate critical care nurse education has historically endorsed these emphases on individual student performance and
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knowledge acquisition, and addressed them as pedagogical priorities through heavily content-driven programs. This tendency to focus on individual performance is not necessarily surprising, given the requirement for individual registration to practice (Australian Health Professional Regulation Authority, 2014). However, individualistic learning, in fostering competition and egocentrism, tends to promote
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behaviours that ultimately can impede high quality team-delivered clinical care.
Although effective teamwork is essential to good patient outcomes (Australian Commission on Safety and Quality in Health Care, 2010a, 2011), there is little explicit pedagogical emphasis on developing a
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collaborative orientation and sense of teamwork amongst nurses. Indeed, there is very little time devoted in a typical syllabus for teaching team development or skills for students to develop the
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confidence required to be proactive team members or leaders. As a direct result of the high costs of formal education and a chronic shortage of specialist nurses there is pressure to compact programs into minimum timeframes while there is a simultaneous burgeoning of content related to increased healthcare complexity (Horns and Turner, 2006). Little wonder that critical care nursing education has preferentially attended to adding more content in the false belief that simply providing more of the same will translate into nurses functioning safely in increasingly complex acute environments. However, given practice changes iteratively with healthcare and technological advances, teaching students life-long learning skills and providing a professional platform for high quality safe care
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ACCEPTED MANUSCRIPT through the development of teamwork and communication skills is far preferable to content heavy, didactic curricula (Parmelee and Michaelsen, 2010).
The collaborative orientation and behaviours essential to effective team performance and the capacity to reason critically and problem solve cooperatively that underpin it are highly desirable skills that can,
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be learned in a procedural way. This paper provides an overview of an educational strategy known as Team-Based Learning (TBL) (Michaelsen and Sweet, 2008) and explores its potential for
transformative learning in critical care nursing programs and its intention to develop confident, work-
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ready graduates with sophisticated team-oriented skills. The discussion follows a successful
implementation of TBL in a suite of critical care courses in Melbourne, Australia in 2009 and suggests that TBL provides real benefits for engaging students and equipping them, well before graduation, for
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high level functioning and effective team membership in the critical care environment.
Background: The Team-Based Learning approach
Team-Based Learning is an innovative learner-centered educational strategy designed to develop high performance learning teams. It can dramatically improve the quality of student learning
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(Michaelsen et al., 2004; Michaelsen et al., 2008) by engaging students in participating actively in their own and others’ learning in a way particularly reflective of ideal cooperative experiential learning encountered in the clinical environment. In TBL, learners are accountable for their learning in and out
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of class through preparation and group discussion (Michaelsen et al., 2008; Michaelsen and Sweet, 2011). Learning teams are formed at the start and remain together in TBL classes throughout the
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program. Teams are formed to ensure maximum diversity and distribution of key course criteria within teams (for example, specialty practice area or duration of clinical experience) and to avoid preexisting, cohesive sub-groups. Instead of supporting the passive reception of learning material, class time is significantly shifted toward the integration and application of newly learned material through highly interactive learning and teamwork. The teacher retains control of content, and acts as both facilitator and content expert but, rather than being responsible for ‘delivering’ the content, the teacher shepherds the essentially self-managing teams through an active learning process. As facilitator, the teacher also takes advantage of opportunities for contingent teaching to fill in gaps or elaborate on principles when required.
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ACCEPTED MANUSCRIPT Five key strategies underpin TBL’s effectiveness in improving student learning outcomes: (1) the reduction or waiving of formal passive lecture time, (2) the promotion of team work in class, (3) TBL’s inbuilt capacity to motivate students to prepare and be on time to class, (4) a central focus on the enhancement of problem-solving skills, and, (5) an emphasis on creating conditions that generate
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high levels of student interaction and engagement in the classroom. In addition, powerful learning incentives are built into the assessment process. The specific sequence and structure of TBL
develops a high level of cohesiveness and trust as groups become lively active learning teams
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engaged in motivated and robust interchanges both within and between teams. As McMahon (2008) points out, the whole process provides a feedback-rich environment. The facilitation of effective team development, nurtured by these conditions, can be considered the single most important factor in the
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effectiveness of TBL as an instructional strategy (Michaelsen and Sweet, 2008).
The Team-Based Learning strategy consists of repeating sequences of three phases (summarized in Table 1):
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Insert Table 1 here [Phases of Team-Based Learning]
Phase 1 consists of pre-class preparation. Students independently study assigned material in order to
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achieve teacher-defined objectives. In Phase 2, as scheduled class time commences, students individually complete a multiple-choice test to demonstrate their readiness to apply the learnings of
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Phase 1. Individual student scores are recorded and submitted. Before the answers are discussed, the preformed permanent teams of 5-7 students then take the same test together, after which their consensus answers are scored and submitted. The latter test strategy gives team members the opportunity to contribute to the team score by negotiating their answers with the team, providing to each other the rationales they have developed based on their prior self-directed study. These ‘readiness assurance’ processes provide an important incentive for students to undertake their selfdirected learning. In Phase 3, the teams collaborate to complete in-class application tasks. At designated times all teams simultaneously share their team’s answers with the entire class for instructive comparison and immediate feedback. Answer sharing stimulates an energetic total-class
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ACCEPTED MANUSCRIPT discussion with groups defending their answers and the teacher assisting to consolidate learning through facilitation and contingent teaching. These activities are based on the core principles of TBL (Haidet et al., 2012; Michaelsen and Sweet, 2011).
Periodically students must evaluate other members of the team for their contributions to the team’s
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productivity. Student assessment based on the ascription of individual and team scores in Phase 2, along with the anonymous peer evaluation scores, ensures that students understand the value of both meaningful preparation and team participation (Letassy et al., 2008). Thus TBL provides a structured
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process for enhancing individual and group accountability (Parmelee et al., 2009). Incentives integral to the assessment process help shift the focus of individual marks toward effective teamwork without close supervision of an instructor. By decentering individual performance and assessment in learning,
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TBL offers the possibility of significantly increasing student engagement and improving student learning outcomes, in both course content and life-long learning skills.
Indeed, programs that have adopted TBL have reported a marked increase in student attendance, student engagement and staff satisfaction (Koles et al., 2010; Levine et al., 2007; Michaelsen and
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Sweet, 2008; Su, 2007). There is a positive association of engagement with desirable academic outcomes such as improved grades and critical thinking (Carini et al., 2006). Results have shown that TBL has facilitated improvements in student academic grades of between 13% and 30% (Michaelsen,
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2013), suggestive of higher levels of student engagement and learning and improved application of problem-solving skills. It is this deep learning and the strengthening of critical reasoning abilities that
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are so difficult to achieve with didactic approaches.
Team-Based Learning creates conditions in which students will work together cooperatively to solve clinical problems and apply their learnings to real world practice situations. Inclusivity is inherent in TBL because it develops team behaviours as students practice interpersonal communication, collaborative decision making, negotiation, giving and receiving feedback, peer review and demonstrating respect for others. Perhaps partly because of the incentives for learning teams to operate collaboratively, inclusively and equitably, TBL is effective in engaging students of non English-speaking background and minority students (Goodson, 2004).
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ACCEPTED MANUSCRIPT Team-Based Learning has been applied successfully in business programs (Freeman, 2012; Michaelsen et al., 2004) and a number of medical courses (Koles et al., 2010; Levine et al., 2004; Okubo et al., 2012; Thompson et al., 2007) used either as an alternative to problem-based learning (PBL) or to radically change a lecture-based teaching approach to improve learning outcomes.
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Techniques of TBL have been developed and evaluated most within education programs of health professionals (Michaelsen et al., 2008). Building on its successful implementation in nursing
undergraduate programs (Clark et al., 2008), we introduced TBL into our critical care postgraduate
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program in 2009. We collected data to evaluate the program and report here on a portion of the qualitative data illuminating the student experience and role TBL can play in developing strong
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teamwork skills in clinicians.
Aim
The aim of the study was to evaluate the impact of TBL on postgraduate nursing students' attitudes to, and perceptions of, TBL as a team learning strategy. In this paper, we report findings related to students’ perceptions of TBL, their comments on the TBL experience and its effectiveness for
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enhancing learnings in the traditionally underemphasized domains of personal and professional growth and team facility in critical care nursing.
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Methods
This study used a structured extended response questionnaire (ERQ) to ascertain students’
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perceptions of their TBL experiences. It was part of a larger research program that explored students learning experiences with TBL classes compared to standard lecture format classes. Ethics approval for the study was granted by the University Human and Research Ethics Committee and students were informed at the commencement of term that observers and guests would be present at some classes to see the new teaching and learning method in action. Issues of privacy and confidentiality for student responses on the ERQ were addressed with deidentified written data and classroom observations performed by research staff. Issues of power relations and potential for coercion were addressed by research staff, not members of the research team, informing students of the study.
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ACCEPTED MANUSCRIPT As noted, students provided written consent to be observed during class and for their deidentified ERQ responses to be analyzed for content and themes (Elo and Kyngäs, 2008). This analysis was informed by the research aims, observed behaviours and issues raised by participants in the ERQ. The word-by-word analysis of these data revealed key issues and themes. The constant comparative technique was applied whereby initial results were analysed for overlap, redundancy, emergence of
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any new themes and relationships between themes (Lincoln and Guba, 1985). This analysis process resulted in final themes that are both descriptive and explanatory. Research rigor in terms of
verification, dependability and confirmability was enhanced through mixed methods design, peer
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collaborations, peer debriefing, rich thick descriptions of data and open transparency about research aims (Lincoln and Guba, 1985; Mays and Pope, 2000; Schneider et al., 2007).
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Team-Based Learning classes were run on a single study day, on alternate weeks, for the 12-week term, with ‘traditional’ lecture presentation provided on the other weeks. The structured ERQ, distributed at term completion, provided anonymous evaluations of the program (see Table 2). Unsolicited written feedback from students and teachers in the classroom and clinical settings and informal verbal feedback from students in class were also incorporated with permission. The
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questions used in the ERQ are listed in Table 2.
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Insert Table 2 here [Questions used in the Extended Response Questionnaire]
Thirty-two questionnaires were distributed with reply paid envelopes. The return rate for the ERQ was
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100% following provision of class time for their completion. Students were aware of the importance of their feedback to the success of the program and were enthusiastic about contributing to its continuation, development and expansion.
Results and discussion The ERQ questions 1, 2, 3, 5, 6 and 11 elicited responses pertinent to this discussion of professional attributes. Relevant responses are reported here, along with pertinent unsolicited comments made in class or submitted electronically. With hindsight we should have ensured the “Why?” question was included in all ERQ questions to invite elaborated responses. Of the analysed responses to questions
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ACCEPTED MANUSCRIPT 1,2,3, 5, 6 and 11 discussed here only seven responses specifically to question 5 only (Which approach do you feel would assist you more in making judgements and decisions in clinical practice―Team-Based Learning or standard lectures?) did not elaborate beyond the answer “TBL”. Thus the extended response questions 1, 2, 3, 6 and 11 provided most of the meaningful data for the
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purposes of this discussion.
Reported here are elements of these responses pertaining to the discussion of the development of professional attributes amongst students in response to TBL, and those centering on professional
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growth, critical thinking capacity and team skills. Comments are reproduced as provided, without alteration of syntax or use of [sic], but completions are added in brackets where the student’s note
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relied for meaning on the survey question or a previous sentence.
Responses were reviewed and collated into thematic categories. Where single responses touched on more than one theme, the response was categorized to all relevant themes and the pertinent thread highlighted in each case in order to maintain the context of the threads. Stand-alone threads have been extracted from whole responses and are reported independently of accompanying threads on a
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different theme. Four experiential themes were nominated and from each of these themes were developed subthemes containing three or more comments each. Categories were discussed and reviewed together by the first and second authors. The emergent experiential themes underscored
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attributes of the mature professional and in many cases are illuminative of the in-process transformation in role from student to independent clinician. The nominated themes and subthemes
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emerging from the data are schematized in Figure 1. As a whole, the main finding of this study was the increased professional growth which students attributed to TBL. Thus, TBL was instrumental in developing professional attributes in critical care nurses.
Insert Figure 1 here [Themes and subthemes]
Within the subthemes belonging to the ‘Motivation to learn’ category, students reported a sense of deadline-generated pressures that helped them commit to study, and a perceived obligation to undertake the pre-class work to contribute usefully to the team effort and avoid looking foolish in front
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ACCEPTED MANUSCRIPT of peers. Students also appreciated a learning environment where opinions were listened to and discussed; this helped them maintain their focus and attention. They were also encouraged to study through the use of targeted resources and recorded lectures which they could access at their own pace and which, along with learning objectives, provided clear direction. Categorized within the theme ‘Engagement’ were comments pertaining to personal and professional growth related to the learning
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experience, a valuing of the team processes and of classroom sociality and enjoyment of the learning process. ‘Learning effectiveness’ encompassed references to new understandings and enhanced retention of concepts, cooperative learning and learning from peers’ understandings and experiences.
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The ‘Critical thinking’ theme included responses that cited the benefits of fresh viewpoints and the discovery of alternative ways of thinking about a problem, and the opportunities to apply concepts and rehearse the constant problem-solving demanded by the clinical context. Furthermore, there was
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recognition by some respondents that TBL provided not only the opportunity to argue, explain, defend and justify their views, but the requirement to do so and that the classroom dialogues were enhancing their learning and gaining them the respect of peers.
Students were enthusiastic about the opportunity to learn within teams. Even if they perceived their
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own team had not functioned as highly as some others, students reported that they preferred TBL as a learning mode over solitary problem-solving because of the opportunity to gain new perspectives. Indeed, a strength of TBL is that the team can solve challenging and complex problems that are
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beyond the reach of even the most talented students working alone, and this has been shown by the developer of TBL, Larry Michaelsen (Michaelsen et al., 1989). The empirical evidence of this is in the
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comparative scoring on the individual and team readiness assurance tests (RATs) completed in Phase 2—data from TBL studies show that over time the teams will always achieve higher scores than the best performing individuals in the class (Michaelsen et al., 1989). Although we did not compare scores for the purposes of this study, all of our students, including the strongest individual performers, were enthusiastic about participating in a team approach to problem-solving and their feedback highlighted both the growth in their individual understandings and their contributions to others’ learning. Comments showed a strong sense of the importance of a functioning team to these learning conditions; the team approach was felt to facilitate individual learning and enhance team relationships, apparent in comments such as:
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ACCEPTED MANUSCRIPT [I am] learning from my peers; clarifying areas of uncertainty within the group
[We are] learning from one another
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[TBL] trains students to think out loud and be able to “teach” each other.
It often left me with a feeling of achievement when I could rationalize and contribute to the
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team’s learning
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Another student pointed out the mutuality that TBL engendered in cohesive teams:
[An advantage of TBL is] working as a member of the team – I am on a really great team – we may not get all the answers correct but we respect and support each other.
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TBL promoted discussion, students suggested, that not only facilitated learning―
[TBL gives] people the chance to offer alternative ideas and rationale
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[The advantages of TBL are:] Seeing how other people approach issues. Sharing knowledge
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and experience
―but equipped students for justified and evidenced decision making in clinical practice:
[I]f you don’t understand something everyone has to go round and explain their
rationales―the discussion helps you remember concepts.
Moreover, students were able to relate the experiences of the learning process to the skills needed in the clinical environment:
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ACCEPTED MANUSCRIPT TBL assist[s] with decision making and communication in clinical practice because [of] all the talking/justifying answers to colleagues. This skill is important in critical care—telling your team mates why you have done what you have done
It was apparent, too, that the process was supporting students in asserting their arguments, and that,
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time and again, the conditions for nurturing thinking skills were assisted by the use of teams:
Team-Based learning...is good training for sound thinking and making sound judgements
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because you have to think out loud and convince team-mates of answers.
but shifting thinking about learning:
TBL is helping the way we think
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It also seemed that for some TBL was not merely opening eyes to alternative views and experiences
[TBL is a ] better way of learning―you are expressing your opinion and views give a rationale
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and sometimes you are surprised by what other members can come up with―it’s amazing because you couldn’t think about the concept/idea yourself
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One of the major benefits of TBL as a learning strategy is the enhancement of critical thinking skills (Michaelsen et al., 2008, McInerney & Fink, 2009, Nelson et al., 2013). Making evidence-based
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judgements and sound clinical decisions are natural evolutionary outcomes of a learning process that demands rationale and justification at every iteration. Indeed, students’ abilities to think effectively are significantly enhanced by the emphasis on facilitating thinking skills in a team context where students learn how to incorporate others’ views, ideas and perspectives and deal with the challenges of differences and concepts not fully grasped before attending class (Chad, 2012).
The students recognized that through this particular approach to learning they were developing deeper understandings and ways of thinking that were transformative. The TBL process had the potential to affect their way of being in practice:
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ACCEPTED MANUSCRIPT Initially I thought that not having any physical notes from TBL was a disadvantage but then I realized that TBL is not about making notes but rather changing my thinking and making me think like a critical care nurse
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I think [with TBL] the student would be better able to prepare, respond with confidence to questions, ask questions and rationalize critically and higher order think.
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It [TBL] has forced you to become confident in your answers as you’ve had to voice these in an open forum, which has led to an increase in self learning
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Because of the interest in the TBL approach (which was new to the University), observers and researchers were present during many of the TBL classes. The students quickly adapted to having observers in class and unselfconsciously concentrated on the tasks. Independent observation by teachers and observers of critical thinking and problem-solving skills emergent in student responses
problem-solving skills.
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to the provided clinical scenarios supported the students’ self-reported growth in confidence and
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Student comments indicated that the TBL program not only enhanced their acquisition of content knowledge, their capacity to apply knowledge and their development as professionals but that the
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enhancement and the realization of deep learning were highly valued:
I believe if the skills used in TBL were developed early in a student’s learning by the end of the course you would have much more confident professionals.
It often left me with a feeling of achievement when I could rationalize and contribute to the team’s learning
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ACCEPTED MANUSCRIPT The approach also reinforced innate desires to contribute to the team effort, building on accomplishment imperatives created in the classroom:
[TBL] makes me do my pre-learning so that I don’t let the team down
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Team-Based Learning makes you prepare more because you are doing it for a team not just individually. I have been more productive this trimester because of TBL
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The safe learning environment acknowledged by students assisted with encouraging contributions to the team discussion:
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[The advantages of TBL are:] Getting to know everyone/relaxed environment/never embarrassed to say wrong answer because you know it will be discussed
[The advantages of TBL are:] mix with peers/actively participated in learning...friendly non-
peers to speak up
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judgemental environment where thoughts and ideas are not ridiculed/ it encourages quieter
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While team membership provides the opportunity for peer learning, team building is an important part of the TBL process (Thomas & McPherson, 2011). It can take weeks for the group to develop into a
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functioning, mature team (Michaelsen et al., 2008). We were careful to establish the assessment processes and explain the peer evaluations to clarify for students the importance of productive group work on their individual grades. Beginning team development was evident early in the term with inclusiveness being observed in the classroom interactions before peer evaluations were first required. In the ERQ items, students indicated that they learned to value and respect teams in the classroom and, by extension, in the workplace where learning and professional growth would continue as students gained experience:
Awesome! Helps knowledge base in a fun way, helps you in team situations back on the ward
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ACCEPTED MANUSCRIPT TBL [is an advantage] because in practice you always discuss care and options with colleagues whereas in lectures it is one person’s opinion or knowledge. [TBL] would assist you more in making judgements and decisions in clinical practice
for some it helped them to find a voice:
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[With TBL] you learn to back yourself
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Furthermore, students saw the TBL approach as assisting their personal and professional growth and
You learn to produce rationale, otherwise your opinion is not valued. ..[Defendability] gains
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the respect of colleagues at work.
One of the unanticipated effects of TBL widely noted by teachers in the clinical setting as well as at the university was the marked acceleration in the development of professional attributes. From an industry perspective it is highly desirable that graduates are work-ready, confident in their abilities and equipped with the necessary team skills to function productively in the workplace. Postgraduate
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critical care students working in hospitals are required to function effectively as caregivers under limited and rapidly decreasing levels of supervision. Students and the rest of the team are advantaged and the quality of care delivery improved if students can attain graduate level functioning as soon as
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possible. In this study, TBL was seen to accelerate the acquisition of specific knowledge and skills, exciting learners and teachers alike. Students reported that peers in the workplace also commented
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on their professional growth and confidence and on their abilities to articulate and justify their clinical decision making. Students appeared particularly willing to question workplace practices and evaluate approaches and rationales, while themselves citing evidence of best practice, skills that the students attributed to their classroom experiences where such skills were developed and rehearsed (Currey et al., 2014a). Thus students felt that they were accepted more readily as contributing members of the health care team; this was a development welcomed by both students and their peers in the workplace (Oldland & Currey, 2014).
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ACCEPTED MANUSCRIPT In our experience, TBL offers real potential for deep learning and provides graduates with capacities for higher level critical thinking, problem solving, and a valuing of team-based solutions in the workforce—all making for more effective team membership and enhanced leadership skills (Currey et al., 2014b). Students were both able to articulate a sense of their own professional growth and acceptance into the health care team as a direct result of their TBL immersion and were able to
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demonstrate in practice the clinical confidence that accelerated their effective team participation and facility. Critical reasoning ability, problem solving and evidenced clinical judgement are expected graduate outcomes and must be prioritized equally with knowledge-based outcomes in critical care
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nursing programs (ACCCN, 2002). Indeed, studies of TBL in postgraduate nursing in the fields of emergency nursing, cardiac and critical care have produced these outcomes (Considine et al, 2013; Considine et al., 2014; Currey et al., 2014b). Understandings of professional development in
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practitioners should encompass non content knowledge-focused developmental dimensions such as team facility and the valuable capacity for giving and responding to feedback as well as cooperative problem solving, clinical planning and care delivery (Parmelee & Hudes, 2012).
Limitations
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This study is limited by its small sample and reliance on a single site. However, students worked in nine different hospital settings and, as with all qualitative research, we were not seeking to generalize findings. We sought students’ perspectives to provide rich meaningful data and to triangulate with the
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quantitative results that have been reported elsewhere. The duration of TBL and each individual’s team experiences may have influenced results, but as with all qualitative studies, such variables were
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not controlled. As noted earlier, the ERQ may have yielded even richer data by asking students ‘why?’ to justify their responses further.
Conclusions
In this study we sought to describe students’ experiences of learning via TBL. Our findings suggest that TBL offers a powerful educational strategy for increasing both student engagement in the classroom and student learning outcomes. It facilitates critical reasoning, effective learning, and engagement with self as learner, with colleagues and the clinical team. We believe that TBL redresses an under-emphasis in critical care nursing education on the development of professional
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ACCEPTED MANUSCRIPT attributes, of which the capacity to value and function productively within a multi-skilled team is a critically important dimension. The response to the TBL experience by nurses in this program was overwhelmingly positive and we have continued to expand TBL into other programs in our Faculty
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with great enthusiasm and delight to our students and staff alike.
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References
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Australian College of Critical Care Nurses 2002, Competency standards for speciality critical care nurses, Australian College of Critical Care Nurses (ACCCN), http://www.acccn.com.au/content/view/119/150/ Australian Commission on Safety and Quality in Health Care, 2010a. National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration. ACSQHC, Sydney. http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/EB5349066738C24CC A2575E70026C32A/$File/national_consensus_statement.pdf Australian Commission on Safety and Quality in Health Care, 2010b. A National Health and Hospitals Network for Australia’s Future – Delivering better health and better hospitals. Commonwealth of Australia, Barton ACT. http://www.health.gov.au/internet/yourhealth/publishing.nsf/Content/reportredbook/$File/HRT_report3.pdf Australian Commission on Safety and Quality in Health Care, 2011. Australian Safety and Quality Framework for Health Care. Putting the Framework into action: Getting started. http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/A711EFB49765583FC A25784C000E13B4/$File/ASQFHCGuideHealthcareteamWEB.PDF. Australian Health Professional Regulation Authority. Accessed September 19, 2014 Available at: https://www.ahpra.gov.au/ Benner, P., 1984 From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addision-Wesley. Carini, R., Kuh, G., Klein, S., 2006. Student engagement and student learning: Testing the linkages. Research in Higher Education 47, 1-32. Chad, P., 2012. The Use of Team-Based Learning as an Approach to Increased Engagement and Learning for Marketing Students: A Case Study. Journal of Marketing Education 34, 128-139. Clark, M., Nguyen, H., Bray, C., Levine, R., 2008. Team-based learning in an undergraduate nursing course, Journal of Nursing Education, 47,111-117. Considine, J., Currey, J., Payne, R., Williamson, S. 2014 Participant evaluation of Team-Based Learning using one-off teams in a hospital setting. Australasian Emergency Nursing Journal 17:68-76 Considine, J., Payne, R., Williamson, S., Currey J., 2013 Expanding nurse initiated x-rays in emergency care using Team-Based learning and one-off teams. Australasian Emergency Nursing Journal, 16, 10-20. Currey, J., Oldland, E., Story, I., Considine, J., 2014a. Team-Based Learning accelerates acquisition of professional practice attributes and knowledge in specialty nurses. APAC Forum, Melbourne Convention Centre Sept 2-3, 2014 Currey J., Oldland E., Considine J., Glanville D., Story I. 2014b Evaluation of postgraduate critical care nursing students' attitudes to, and experiences with, Team-Based Learning: A descriptive study. Intensive and Critical Care; DOI: 10.1016/j.iccn.2014.09.003 Elo, S., Kyngäs, H., 2008. The qualitative content analysis process, Journal of Advanced Nursing, pp. 107-115. Freeman, M., 2012. To adopt or not to adopt innovation: A case study of team-based learning, International Journal of Management Education, pp. 155-168.
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Goodson, P., 2004. Working with nontraditional and underprepared students in health education., in: Michaelsen, L., Knight, A., Fink, D. (Eds.), Team-based learning: A transformative use of small groups in college teaching. Stylus, Sterling, VA, pp. 73-93. Haidet, P., Levine, R., Parmelee, D., Crow, S., Kennedy, F., Kelly, P., Perkowski, L., Michaelsen, L., Richards, B., 2012. Perspective: Guidelines for reporting team-based learning activities in the medical and health sciences education literature. Academic Medicine 87, 292-299. Horns, P.N., Turner, P.S. 2006. Funding in higher education: where does nursing fit? Journal of Professional Nursing 22(4),221-225. Koles, P., Stolfi, A., Borges, N.J., Nelson, S., Parmelee, D., 2010. The impact of team-based learning on medical students' Academic Performance. Academic Medicine 85, 1739-1745. Letassy, N., Fugate, S., Medina, M., Stroup, J., Britton, M., 2008. Using team-based learning in an endocrine module taught across two campuses. American Journal of Pharmaceutical Education 72(5),103. Levine, R., Kelly, P., Karakoc, T., Haidet, P., 2007. Peer evaluation in a clinical clerkship: Students' attitudes, experiences, and correlations with traditional assessments. Academic Psychiatry 31, 19-24. Levine, R., O'Boyle, M., Haidet, P., Lynn, D., Stone, M., Wolf, D., Paniagua, F., 2004. Transforming a clinical clerkship with team learning. Teaching and Learning in Medicine 16, 270-275. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic inquiry. Sage, Beverly Hills, CA. Mays, N., Pope, C., 2000. Quality in qualitative health care, in: Pope, C., Mays, N. (Eds.), Qualitative research in health care BMJ Books, London, pp. 89-101. McHugh MD, Lake, ET., 2010. Understanding clinical expertise: Nurse education, experience, and the hospital context. Research in Nursing & Health 33:276-287. McInerney, M., Fink, L., 2009. Team-Based learning enhances long-term retention and critical thinking in an undergraduate microbial physiology course. Journal of Microbiology & Biology Education, North America, 4, Dec. 2009. Available at: . Date accessed: 18 Sep. 2014. McMahon, K., 2008. Team Formation, in: 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. Stylus, Sterling, VA, pp. 85-88. Michaelsen, L., 2013. Team-Based Learning: Extending the practice and the community, 12th Annual Team-Based Learning Collaborative (TBLC) Conference, San Diego CA. Michaelsen, L., Knight, A., Fink, D., 2004. Team-based learning: a transformative use of small groups in college teaching. Stylus Publishing, Sterling, Virginia. Michaelsen, L., Parmelee, D., McMahon, K., Levine, R., 2008. Team-based learning for health professions education: A guide to using small groups for improving learning. Stylus Publishing, Sterling, Virginia. Michaelsen, L., Sweet, M., 2008. The essential elements of team-based learning. New Directions for Teaching and Learning 116, 7-27. Michaelsen, L., Sweet, M., 2011. Team-Based Learning. New Directions for Teaching and Learning 128, 41-51. Michaelsen, L., Watson, W., Black, R., 1989. A Realistic Test of Individual Versus Group Consensus Decision Making. Journal of Applied Psychology 74, 834-839. Nelson, M, Allison, SD, McCollum, M, Luckey, SW, Clark, DR, Paulsen, SM, Malhotra, J & Brunner, LJ., 2013. The regis model for pharmacy education: A highly integrated curriculum delivered by Team-Based Learning™ (TBL), Currents in Pharmacy Teaching and Learning, 5, 555-63. Oldland, E., Currey, J., 2014. Students’ perception of the role of Team-Based Learning in shaping individual learning style, team skills and clinical practice. 14th Annual Team-Based Learning Conference, Fort Worth, March 6-8, 2014 Okubo, Y., Ishiguro, N., Suganuma, T., Nishikawa, T., Takubo, T., Kojimahara, N., Yago, R., Nunoda, S., Sugihara, S., Yoshioka, T., 2012. Team-based learning, a learning strategy for clinical reasoning, in students with problem-based learning tutorial experiences. Tohoku Journal of Experimental Medicine 227, 23-29. Parmelee, D., DeStephen, D., Borges, N., 2009. Medical students' attitudes about team-based learning in a pre-clinical curriculum, Med Edu Online, pp. 1-7. Parmelee, D. Michaelsen, L., 2010. Twelve tips for doing effective Team-Based Learning (TBL). Medical Teacher 32, 118-122. Parmelee, D. Hudes, P., 2012, 'Team-Based Learning: A relevant strategy in health professionals' education', Medical Teacher, 34, 411-3.
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Schneider, Z., Whitehead, D., Elliott, D., Lobiondo-Wood, G., Haber, J., 2007. Nursing and Midwifery Research. Methods and Appraisal for Evidence-Based Practice 3rd ed. Mosby Elsevier., Marrickville. Su, A., 2007. The impact of individual ability, favorable team member scores, and student perception of course importance on student preference of team-based learning and grading methods. Adolescence 42, 805-826. Thomas, M.D. & McPherson, B.J., 2011, Teaching positive psychology using Team-Based Learning, The Journal of Positive Psychology, 6, 487-91. Thompson, B., Schneider, V., Haidet, P., Levine, R., McMahon, K., Perkowski, L., Richards, B., 2007. Team-based learning at ten medical schools: Two years later. Medical Education 41, 250-257.
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ACCEPTED MANUSCRIPT Table 1 Phases of Team-Based Learning Phases of Team-Based Learning PHASE 2
PHASE 3
Pre-class learning
Readiness Assurance
Application of course concepts
Study materials provided
Individual multi-choice test
Teacher-set objectives Answers submitted
Team assignments
Cooperative problem solving
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Instructor facilitated class discussion
i. Team discussions in negotiating answers
Peer evaluation
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iii. Instructor feedback, answers discussed
ACCEPTED MANUSCRIPT Table 2 Questions used in the Extended Response Questionnaire
Which class sessions have you found to be more engaging―Team-Based Learning or standard lectures? Why? 2. Which class sessions do you feel have been most effective in helping you meet the learning outcomes for this unit this trimester―Team-Based Learning or standard lectures? Why? 3. What have been the advantages of the Team-Based Learning sessions this trimester? 4. What have been the disadvantages of the Team-Based Learning sessions this trimester? 5. Which approach do you feel would assist you more in making judgements and decisions in clinical practice―Team-Based Learning or standard lectures? 6. Would you prefer to have more or less Team-Based Learning sessions in your course? Why? 7. How often would you like Team-Based Learning sessions if you had this trimester over again? 8. Would you like to sit closer together with the group when doing TBL? 9. What would you say to prospective students about Team-Based Learning? 10. What advice do you have for the educator regarding the conduct of TBL sessions? What works well? 11. Please feel free to make any other comments.
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1.
ACCEPTED MANUSCRIPT Figure 1.
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Themes from the Extended Response Questionnaire