Uncover it, students would learn leadership from Team-Based Learning (TBL): The effect of guided reflection and feedback

Team-based learning in health professions education: an umbrella review

BACKGROUND

Team-Based Learning (TBL) has garnered considerable attention in education research. To consolidate the existing evidence, we conducted an umbrella review with four objectives: (a) to identify TBL review characteristics, (b) to synthesize findings from previous reviews regarding TBL effectiveness and outcomes, (c) to determine which student groups benefit most, and (d) to identify the most and least researched elements.

METHODS

The Joanna Briggs Institute (JBI) methodology was followed: [1] Search strategy and literature search [2] Screening and Study Selection [3] Assessment of methodological quality [4] Data collection, and [5] Data summary. We utilized Endnote, Excel, and MAXQDA for efficient project management and analyzing data.

RESULTS

Analyzing twenty-three reviews spanning from 2013 to 2024, we found a peak in TBL research in 2022 including more than 312 unique primary studies involving more than 63,987 participants. Notably, the United States and China accounted for over 61% of the total primary articles focused on students from medicine, nursing, pharmacy, and dentistry. Evidence supports the superiority of TBL in enhancing cognitive outcomes. However, findings related to retention are mixed. Insufficient evidence exists to draw robust conclusions when comparing TBL with other active learning methods. TBL demonstrates favorable outcomes in terms of clinical performance and engagement. Non-technical skills show mixed results. Notably, TBL positively impacts self-study, learning ability, decision-making, and emotional intelligence. Faculty experiences reveal an initial increase in workload, but generally hold positive attitude. Faculty development remain limited in duration and scope. Freshmen, academically weaker students, undergraduates, Chinese female students, and nursing students appear to benefit most from TBL. Team formation and size are the most frequently studied elements.

CONCLUSION

TBL holds promise for improving learning outcomes, but ongoing investigation is essential to maximize its impact in diverse educational contexts. This umbrella review underscores the need for further research in specific areas i.e. effective pre-class learning methods and faculty workload.

A systematic scoping review of group reflection in medical education

BACKGROUND

Reviewing experiences and recognizing the impact of personal and professional views and emotions upon conduct shapes a physician's professional and personal development, molding their professional identity formation (PIF). Poor appreciation on the role of reflection, shortages in trained tutors and inadequate 'protected time' for reflections in packed medical curricula has hindered its integration into medical education. Group reflection could be a viable alternative to individual reflections; however, this nascent practice requires further study.

METHODS

A Systematic Evidence Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure a review of group reflections in medical education. Independent searches of articles published between 1st January 2000 and 30th June 2022 in bibliographic and grey literature databases were carried out. Included articles were analysed separately using thematic and content analysis, and combined into categories and themes. The themes/categories created were compared with the tabulated summaries of included articles to create domains that framed the synthesis of the discussion.

RESULTS

1141 abstracts were reviewed, 193 full-text articles were appraised and 66 articles were included and the domains identified were theories; indications; types; structure; and benefits and challenges of group reflections.

CONCLUSIONS

Scaffolded by current approaches to individual reflections and theories and inculcated with nuanced adaptations from other medical practices, this SSR in SEBA suggests that structured group reflections may fill current gaps in training. However, design and assessment of the evidence-based structuring of group reflections proposed here must be the focus of future study.

Understanding strategies that foster nurses to act as clinical leaders in hospitals: A realist review

AIM

To identify strategies that develop clinical nursing leadership competencies among staff nurses, and to explain the contextual elements and mechanisms that underpin the development of clinical nursing leadership competencies.

DESIGN

Realist review according to the Realist and Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES).

DATA SOURCES

PubMed, Embase, CINAHL, Web of Science, Wiley Online Library, PsycInfo and ProQuest were searched from January 2000 until October 2022.

REVIEW METHODS

Three iterative phases: (1) development of initial programme theory, (2) structured searches for relevant published and grey literature and (3) data synthesis and interpretation by researchers and theory triangulation, and discussions within the research group.

RESULTS

Multiple context-mechanism-outcome configurations were extracted from 10 reports that explain how, under what circumstances and why strategies can facilitate (or discourage) staff nurses to act as clinical leaders. Reports were both quantitative and qualitative in design, originating from English-speaking countries only.

CONCLUSIONS

A logic model was developed and suggests four contexts and five mechanisms underlying the development of clinical nursing leadership. Growth in clinical nursing leadership was mainly experienced through experiential learning, which was enhanced by a supportive relationship with a coach or mentor, the use of reflective practices and modelling from other leaders. Furthermore, a supportive work environment triggers ownership, confidence and motivation, and thereby growth in clinical nursing leadership competencies.

IMPACT

Fostering competencies for clinical leadership among staff nurses requires multifaceted strategies. Strategies are successful if, and only if, they combine learning by doing, by knowing and by observing, and establish a responsive work environment. Hospital policy should ensure that staff nurses have access to reciprocal relationships with role models or a coach. In order to grow as clinical nurse leader, ownership and self-reflection on own leadership behaviour need to be facilitated.

NO PATIENT OR PUBLIC CONTRIBUTION

Prospero ID CRD42021292290.

Learning Collaborative Clinical Reasoning in Healthcare Education: An Integrative Review

BACKGROUND

Collaborative clinical reasoning (CCR) occurs when two or more healthcare professionals reflect and negotiate an issue regarding patient's situation or care. This represents a crucial learning goal that needs to be achieved during healthcare education.

PURPOSE

To describe the characteristics of and the pre-conditions for learning collaborative clinical reasoning in healthcare education.

METHOD

An integrative review was conducted. A systematic search was carried out in May 2020 (updated in August 2022) in four databases (CINAHL, Pubmed/Medline, Scopus and Eric/EBSCO). Thirty-three peer-reviewed research articles met the inclusion criteria and were included into a data quality appraisal and analysis. The data was analysed with inductive content analysis.

RESULTS

The characteristics of learning collaborative clinical reasoning were described using the following categories: 1) the collaborative clinical reasoning learning method 2) the collaborative clinical reasoning learning environment and 3) the collaborative clinical reasoning learners. The pre-conditions for learning collaborative clinical reasoning were described using the following categories: 1) the learning situation when learning collaborative clinical reasoning, 2) interaction when learning collaborative clinical reasoning and 3) clinical context when learning collaborative clinical reasoning. The learning situation includes the pedagogical preparation before the learning of collaborative clinical reasoning. The interaction consists of facilitation, feedback and peer communication during the learning of collaborative clinical reasoning. The clinical context utilized in the learning of collaborative clinical reasoning needs to be realistic and familiar for the students.

CONCLUSIONS

The results indicate that interventions enhancing collaboration and clinical reasoning apply a variety of learning methods, however there are certain characteristics of and pre-conditions for learning collaborative clinical reasoning to be considered.

Does your group matter? How group function impacts educational outcomes in problem-based learning: a scoping review

BACKGROUND

Problem-based learning (PBL) is a common instructional method in undergraduate health professions training. Group interactions with and within PBL curricula may influence learning outcomes, yet few studies have synthesized the existing evidence. This scoping review summarized the literature examining the influence of group function on individual student PBL outcomes. Following Kirkpatrick's framework, experiential, academic, and behavioral outcomes were considered. The impacts of three aspects of group function were explored: (1) Group Composition (identities and diversity), (2) Group Processes (conduct and climate, motivation and confidence, and facilitation), and (3) PBL Processes (tutorial activities).

METHODS

A literature search was conducted using Medline, CINAHL, and APA PsychInfo from 1980-2021, with the help of a librarian. English-language empirical studies and reviews that related group function to learning outcome, as defined, in undergraduate health professions PBL curricula were included. Relevant references from included articles were also added if eligibility criteria were met. The methods, results, discussions, and limitations of the sample were summarized narratively.

RESULTS

The final sample (n = 48) varied greatly in context, design, and results. Most studies examined junior medical students (n = 32), used questionnaires for data collection (n = 29), and reported immediate cross-sectional outcomes (n = 34). Group Processes was the most frequently examined aspect of group function (n = 29), followed by Group Composition (n = 26) and PBL Processes (n = 12). The relationships between group function and outcomes were not consistent across studies. PBL experiences were generally highly rated, but favorable student experiences were not reliable indicators of better academic or behavioral outcomes. Conversely, problematic group behaviors were not predictors of poorer grades. Common confounders of outcome measurements included exam pressure and self-study.

CONCLUSIONS

The main findings of the review suggested that (1) group function is more predictive of experiential than academic or behavioral PBL outcomes, and (2) different Kirkpatrick levels of outcomes are not highly correlated to each other. More research is needed to understand the complexity of group function in PBL tutorials under variable study contexts and better inform curricular training and design. Standardized tools for measuring PBL group function may be required for more conclusive findings.

Metamotivation in medical students: Explaining motivation regulation strategies in medical students

BACKGROUND

Metamotivation is a process that students use to monitor their motivational states to reach their academic goals. To date, few studies have addressed the ways that medical students manage their motivational states. This study aim to identify the motivational strategies of medical students as they use the metamotivational process to monitor and control their motivational states.

MATERIALS AND METHODS

This qualitative study uses directed content analysis of the narrative responses of 18 medical students to draft an in-depth and semistructured interview protocol which were conducted through WhatsApp due to social distance restrictions of COVID-19. Data were collected, encoded, and analyzed using deductive content analysis approach descripted by Elo and Kyngäs.

RESULTS

Seven main themes were extracted as the motivational strategies of medical students including "regulation of value," "regulation of situational interest," "self-consequating," "environmental structuring," "efficacy management," "regulation of relatedness," and "regulation of situational awareness." In this study by identifying new strategies, we provide a broader framework of metamotivational strategies in the field of the progression of learners in medical education.

CONCLUSION

Medical students use a variety of strategies to regulate their academic motivation. To sustain and improve the motivation of medical students, identifying and strengthening metamotivational strategies is the first step.

Reflective Essays During Clerkship Following a Pre-clerkship Leadership Curriculum

INTRODUCTION

Leadership curricula in medical student education require assessment - to determine if leadership skills can be taught to medical students and applied during clinical and medical team interactions to aid in medical student leadership development.

OBJECTIVES

To examine whether medical students applied principles of their pre-clerkship leadership curriculum (character, competence, context, and communication elements across four levels: personal, interpersonal, team, and organizational) during an internal medicine clerkship.

METHODS

Using art as a prompt, Uniformed Services University (USU) internal medicine clerkship students completed a structured reflection on a critical incident. Medical student essays written during a 10-week internal medicine clerkship at USU in 2019 were collected. 158 medical student submissions were de-identified and analyzed.

RESULTS

Sixty-four submissions (40.5%) focused on leadership or leadership and professionalism. Students identified as male (n = 34, 53%), female (21, 33%), or not reported (9, 14%). Most, 48 (75%), did not describe PITO explicitly in their essay. They instead focused on personal and interpersonal aspects (17, 27%) of leadership, the attending physicians they worked with (33, 52%), and effective leadership strategies (46, 72%). The most common themes written about were responsibility (30, 47%), teamwork (18, 28%), competence (17, 27%), and character/integrity (15, 23%).

CONCLUSION

Although the students' explicit use of the PITO model was limited, student essays centered on themes that reflected leadership concepts taught in pre-clerkship years, such as character, competence, and responsibility. This study demonstrates that an internal medicine clerkship rotation can feasibly implement a leadership reflection.

Determining Indicators of High-Quality Application Activities for Team-Based Learning

Objective. To determine the indicators of quality for application activities in pharmacy team-based learning (TBL). Methods. A modified Delphi process was conducted with pharmacy TBL experts. Twenty-three experts met the inclusion criteria, including having at least four years of TBL experience, designing at least eight TBL sessions, training others to use TBL, and authoring a peer-reviewed TBL pharmacy paper. In round 1, panelists responded to five open-ended questions about their successful TBL applications activities, including satisfaction with the activity and methods for creating positive student outcomes. In round 2, panelists indicated their level of agreement with the round 1 quality indicators using a four-point Likert rating. Consensus was set at 80% strongly agree/agree. In an open comment period, panelists provided suggestions to help expand the indicator descriptions. Indicators were verified based on TBL and the education literature. Results. Twenty panelists (87% of those eligible) responded in round 1 and 17 (85% participation) in round 2. Sixteen quality indicators were identified in round 1, with 14 achieving consensus in round 2. "Uses authentic pharmacy challenges or situations" (88% strongly agree/agree) and "incorporates or provides effective feedback to groups" (88% strongly agree/agree) met consensus. However, "has multiple right answers" (76% strongly agree/agree) and "incorporates elements from school specific emphases (eg, faith, underserved)" (53% strongly agree/agree) did not reach consensus. Conclusions. These indicators can assist faculty members in designing application activities to provide high-quality TBL exercises that promote deep thinking and engaged classroom discussion. The indicators could also guide faculty development and quality improvement efforts, such as peer review of application activities.

Reflective and feedback performances on Thai medical students' patient history-taking skills

BACKGROUND

Reflective practice (RP) plays a crucial role in encouraging learners to think critically and consciously about their performances. Providing constructive feedback can further enhance RP. But non-Western learners might face different learning barriers compared to learners in the West, where RP originated.

METHODS

In this retrospective study, we assessed RP and feedback performances on Thai medical students' patient history-taking skills. We applied RP and peer feedback, along with feedback from the instructors, during the history-taking sessions of the ten-week introduction course for fourth-year medical students. Twelve history-taking sessions were used for the analysis. Two instructors assessed students' reflective performance and categorised them into one of the six stages of Gibbs' reflective cycle; their feedback performances were analysed using Pendleton's model. We investigated the correlations between students' overall grade point average (GPAX) and patient history-taking scores on the Objective Structured Clinical Examination (OSCE). Students' opinions of the RP teaching method were also collected.

RESULTS

All (n = 48) students participated in our study. The students' mean age was 21.2 ± 0.5 years. The majority of the students were female (64.6%). The data indicated that 33 and 4% of the participants were categorised into the evaluation stage and action plan stage of Gibbs' reflective cycle, respectively. In addition, 22 and 15% of the participants were able to state what their peers did well and suggest how peers could improve their skills, respectively. All students passed the minimum passing level of four history-taking OSCE stations. Participants agreed that RP was a useful tool (mean 9.0, SD 0.1), which enhanced their thought processes (mean 8.4, SD 0.2) and future performances (mean 8.2, SD 0.2). However, there was no correlation between the students' highest Gibbs' reflection levels and their history-taking OSCE scores.

CONCLUSIONS

RP, together with feedback, proved to be a useful technique to help fourth-year Thai medical students improve their reflection skills, enhance their medical knowledge, and improve patient history-taking skills. Further study with longer monitoring is required to further explore negative and positive influential factors affecting students' achievement of better reflection performances.

A decade of reform in medical education: Experiences and challenges at Tehran University of Medical Sciences

PURPOSE

In this paper, we present the major curricular reform in MD program of Tehran University of Medical Sciences, the oldest and the largest medical university in Iran, initiated about a decade ago.

MATERIALS AND METHODS

Following a comprehensive program evaluation, many of the basic challenges of the traditional curriculum were revealed, namely, lack of pre-defined competencies for graduates, over-reliance on teacher-centered teaching methods, over-emphasis on knowledge base in student assessments, and focusing solely on biomedical aspects of patient care. In 2010, a vision statement for reform was created and approved by the University Council. The new curriculum was launched in 2011.

RESULTS

The changes included: revising the content of the courses, assimilating horizontal and vertical integration, emphasizing clinical skills, encouraging active involvement in patient management, providing more opportunity for supervised practice, integrating behavioral and psychosocial topics into the curriculum, incorporating interactive teaching methods, assessing students' higher levels of cognition, and strengthening workplace assessments. To evaluate the changes, data were continuously collected and analyzed from the beginning.

CONCLUSIONS

Changing the curriculum of an MD program is a laborious task which should be planned and undertaken carefully and cautiously. It is an endless, yet invaluable and satisfying endeavor toward better future.

Leadership Identity Development Through Reflection and Feedback in Team-Based Learning Medical Student Teams

PROBLEM

Studies on leadership identity development through reflection with Team-Based Learning (TBL) in medical student education are rare. We assumed that reflection and feedback on the team leadership process would advance the progression through leadership identity development stages in medical students within the context of classes using TBL.

INTERVENTION

This study is a quasi-experimental design with pretest-posttest control group. The pretest and posttest were reflection papers of medical students about their experience of leadership during their TBL sessions. In the intervention group, TBL and a team-based, guided reflection and feedback on the team leadership process were performed at the end of all TBL sessions. In the other group, only TBL was used. The Stata 12 software was used. Leadership Identity was treated both as a categorical and quantitative variable to control for differences in baseline and gender variables. Chi-square, t tests, and linear regression analysis were performed.

CONTEXT

The population was a cohort of 2015-2016 medical students in a TBL setting at Tehran University of Medical Sciences, School of Medicine. Teams of four to seven students were formed by random sorting at the beginning of the academic year (intervention group n = 20 teams, control group n = 19 teams).

OUTCOME

At baseline, most students in both groups were categorized in the Awareness and Exploration stage of leadership identity: 51 (52%) in the intervention group and 59 (55%) in the control group: uncorrected χ²(3) = 15.6, design-based F(2.83, 108) = 4.87, p = .003. In the posttest intervention group, 36 (36%) were in exploration, 33 (33%) were in L-identified, 20 (20%) were in Leadership Differentiated, and 10 (10%) were in the Generativity. None were in the Awareness or Integration stages. In the control group, 3 (20%) were in Awareness, 56 (53%) were in Exploration, 35 (33%) were in Leader Identified, 13 (12%) were in Leadership Differentiated. None were in the Generativity and Integration stages. Our hypothesis was supported by the data: uncorrected χ²(4) = 18.6, design-based F(3.77, 143) = 4.46, p = .002. The mean of the leadership identity in the pretest, intervention group equaled 1.93 (SD = 0.85) and the pretest, control group mean was 2.36 (SD = 0.86), p = .004. The mean of the posttest, intervention group was 3.04 (SD = 0.98) and posttest, control group mean was 2.54 (SD = 0.74), T = -4.00, design df = 38, p < .001, and adjusted on baseline and gender T = -8.97, design df = 38, p < .001.

LESSONS LEARNED

Reflection and feedback on the team leadership process in TBL advances the progression in stages of leadership identity development in medical students. Although the TBL strategy itself could have an impact on leadership identity development, this study demonstrates that when a reflection and feedback on leadership intervention are added, there is much greater impact.