Background

Rapid changes in medical practice have a large impact on the demands faced by educators in preparing students for future participation in a multifaceted healthcare workforce. The practice of medicine increasingly requires multi-professional team-work in order to provide the best patient outcomes [1]. Competencies required by medical graduates encompass the ability to effectively collaborate, communicate and problem solve. Graduates must be trained as lifelong learners, capable of accessing, assessing and synthesising a wealth of information relevant to health care [1]. For at least four decades many medical schools have relied on the learning environment provided within a Problem Based Learning (PBL) approach, in which tutors facilitate small groups so as to allow self-directed learning and experiential learning activity. However, larger class sizes and budget constraints have seen the requirement for new models of small group teaching that promote collaborative learning [2].

The learning needs of medical students are also thought to have changed over time. Today’s medical students are highly interconnected, enjoying teamwork and collaborative practice, and the use of social media for learning [3]. They are also reported to have a unique outlook on assessment, desiring continuous, explicit feedback. They want structured learning activities, with clear expectations, and enjoy a sense of accomplishment on their achievements. In addition to modifications in teaching methods, educators have embraced technological advancement in the delivery of medical education. Adopting blended learning models has the potential to enhance student engagement both inside and outside of the class room [4]. In particular, the ‘flipped’ classroom approach has the capacity to maintain the collaborative nature of learning within large class structures [5], and is being increasingly adopted in health professional education [6]. The conflation of these issues has seen many medical schools adopt the model of Team-based learning in place of Problem-based learning [7, 8].

Within medical education concerns have been raised with the larger class size approach in TBL, the use of the flipped classroom approach; the reduction in group level facilitation in favour of class level facilitation; and the competitive nature of the readiness assurance testing. These concerns suggest that the learning environment in TBL isn’t conducive to co-operative or collaborative learning. However, there is very little literature reported addressing this. An opportunity to fill this gap arose with the introduction of TBL in Year 1 of a hybrid PBL graduate entry medical program in a large research intensive University, as a small group, blended teaching method in place of PBL [9]. In the study reported in this paper, we were interested to qualitatively explore students’ and teachers’ experience of TBL from a social and collaborative learning perspective.

Conceptual framework

Sociocultural learning theories assist our understanding of how students learn from each other, and how teachers construct their learning environments. It is thought that learning environments influence students’ learning process through regular social interactions with peers, teachers and experts. Teachers have the capacity to create learning environments that maximise learning ability by supporting collaboration, discussion and feedback. The theoretical concept of communities of practice is often utilised in medical education literature [10]. First described by Lave & Wenger, there are three key structural elements to the communities of practice [11]:

  1. 1)

    Joint enterprise: a shared domain of interest and a shared desire for proficiency in a subject

  2. 2)

    Mutual engagement: joint activities that promote collaboration and development of learning relationships

  3. 3)

    Shared repertoire: promotion of a shared language, resources, concepts, experiences and tools used and develop through interactions

By understanding the factors that assist in the development of a community of practice within the TBL structure and setting, we sought to address the research gap by qualitatively exploring students’ and teachers’ experience and views of TBL in Year 1 of a graduate entry medical program. Our specific research question was, “What are the students’ and teachers’ experience and views of TBL in Year 1 of a graduate entry program, as considered through the conceptual lens of communities of practice?”

Methods

Study context

Although the context of the study has been previously described [9], the data collected and analysed in this current study has not been previously used, and the research question for this study is unique. In 2016, at the time of this study, the Sydney Medical Program (SMP) offered a hybrid PBL based curriculum within its 4 year graduate entry medical program. Students attended PBL classes twice per week, for 1.5 h each class.

Sampling and participants

This study was carried out in 2016, when there was a cohort of 350 Year 1 medical students enrolled in the University of Sydney medical program. Convenience sampling was used to select 169/350 (48%) of these Year 1 students, who were required to complete three TBL sessions during one of the following teaching blocks: Musculoskeletal, Respiratory or Cardiovascular. Students were assigned to one of three TBL ‘classes’: Musculoskeletal (n = 56), Respiratory (n = 59) or Cardiovascular (n = 54). Each student within this sample completed a total of three TBLs within their class. Within each of these classes, students were assigned to their permanent TBL teams, consisting of five or six students per team. Students were assigned to their teams based on whether they had a science or non-science background, and on gender, so that each team had a diverse mix of students.

Structure of team-based learning

The TBL sessions were held once per week for 2 hours. Nine senior academic clinicians participated as facilitators: three Rheumatologists, three Respiratory physicians, and three Cardiologists. Facilitators consistently attended every TBL in their specialty, that is facilitator teams were consistent. TBL methods were followed as outlined in Table 1. Out of class, we provided pre-class preparation by way of essential online readings and/or pre-recorded lectures. In class we delivered the individual readiness assurance test (IRAT), consisting of 10 multiple choice questions, with one single best answer. This was followed by the very same test being delivered as a team readiness assurance test (TRAT), followed by immediate feedback led by the content experts. Students then moved on to the clinical case-based problem-solving activities, consisting of approximately five problems that were based around a patient case.

Table 1 TBL structure
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Data collection and analysis

At the completion of each block of teaching, all students who participated in the TBLs (n = 169) were invited to attend focus groups. Additionally, all facilitators were invited to attend individual interviews. Semi-structured question guides developed from communities of practice literature, and from discussion with the all authors were used to lead the focus groups and interviews. The focus groups and interviews were conducted by the first author, an experienced medical education researcher, trained in the facilitation of focus groups and interviews. Focus groups and interviews were recorded and transcribed verbatim. Thematic analysis was undertaken using Framework Analysis [12]. This was conducted by the first author on a sample of the data, with the aim to identify recurrent themes and subthemes in the dataset and inform the development of a coding framework. Following a discussion with all authors, a coding framework was developed to code the entire dataset through the theoretical lens of communities of practice.

Ethics approval

Ethics approval was gained from the University of Sydney Human Research Ethics Committee. Approval project number: 2016/136.

Results

In total 34/169 (20%) of students who participated in the TBLs attended one of five focus groups. Two focus groups were held at the end of the Rheumatology block, two at the end of the Respiratory block, and one at the end of the Cardiology block. Of the student focus group participants, 19 were male, and 15 were female. Three facilitators (3/9, 33%) were interviewed, including two rheumatologists and one respiratory physician.

All data from the focus groups and interviews are presented using the conceptual framework of the communities of practice. The theme of ‘joint enterprise’ is illustrated in Table 2. Students and facilitators found that the specified pre-reading and pre-recorded lectures ensured that students came to class with sufficient requisite knowledge as a mechanism to increase their willingness to integrate and apply this information, ultimately increasing their engagement. In class, the combined expertise and clinical experience of facilitators, with immediate feedback helped groups to work both independently and collaboratively. Facilitators found working with their peers in the TBLs to be a rewarding experience. The theme of ‘mutual engagement’ is illustrated in Table 3. Students and staff found the TRAT, and the use of small groups promoted collaboration and teamwork, but also gave individual students equal opportunity to contribute to their team. Facilitators felt the structure and organisation of TBL made students accountable for their learning and team contributions, and also brought about practical efficiencies in learning and teaching. The theme of ‘shared repertoire’ is illustrated in Table 4. Students and facilitators agreed that the use of authentic clinical problems in TBL provided an opportunity to improve student understanding by encouraging self-reflection, and the means to identify knowledge gaps, and build on prior knowledge.

Table 2 Participants’ responses regarding perceptions of their experiences that related to “Joint enterprise”
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Table 3 Participants’ responses regarding perceptions of their experiences that related to “Mutual engagement”
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Table 4 Participants’ responses regarding perceptions of their experiences that related to “Shared repertoire”
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Discussion

We sought to qualitatively explore students’ and teachers’ perceptions of TBL during Year 1 of the Sydney Medical Program, using the theoretical framework of ‘communities of practice’. Within this framework, knowledge is developed as a social, rather than individual feature, which hinges on the concept of “distributed cognition”, where students are dependent upon the knowledge of their peers and resources. In our TBL model, learning involved a process of collaboration within teams, and also between teams as a larger student body, where basic science and medical knowledge and skills were socially constructed. While there is some overlap between themes, the students’ and teachers’ joint enterprise, mutual engagement, and shared repertoire in the TBL classes facilitated learning and enriched the class environment.

Joint enterprise

Joint enterprise refers to a shared domain of interest, and a shared desire for proficiency in a subject [11]. Co-teaching in TBL, with meaningful teaching-learning processes to amalgamate theoretical knowledge with clinical application, was appealing to both teachers and learners.

Teachers described the positive experience of “working with other experts in a collegial atmosphere” as “rewarding” and “positive”. The guidance and feedback they provided to students as co-teachers, formed an integral part of the class process. In line with our findings, evidence suggests that co-teaching is effective in generating student interest, engagement, knowledge acquisition and retention [13]. Students reported the immediate feedback, and relevant clinical context provided by the specialist clinicians, helped their learning. The facilitators “enjoy(ed) going through the MCQs and elaborating on the correct answers”. They shared information and experience from their specialised areas, giving students more motivation and purpose to master that subject. Students felt having experts as teachers shaped the quality of their learning.

Students and teachers alike valued the ‘flipped classroom’ format of TBL. Students felt the online pre-reading and recorded lectures enhanced their engagement in the subsequent TBL classes, particularly in the small-group work. Order and commitment were gained by students having the same preparation requirements. The benefits of the flipped classroom model are reported as being the use of more complex cases, with an increased opportunity for clinically relevant teaching; and enhanced teamwork, with students building on their peers’ knowledge and skills (Chen et al., 2017).

Mutual engagement

Mutual engagement refers to joint activities that promote collaboration and development of learning relationships [11]. The specific steps and structure of the TBL process (preparation, IRAT, TRAT, problem solving activities, feedback) helped to engage students. This is in line with literature suggesting that in a community of practice, students move beyond active learning as individuals by participating in structured, collaborative learning activities that are engaging, interactive and relevant [14].

A clear strength of the TBL was having multiple groups in the one room, and having small individual teams of five to six students. Inter- and intra-group relationships were developed with guidance from facilitators. Students benefited from this participation, largely through the power of interaction, with the development of friendly competition and camaraderie. Active learning opportunities that engage participants have the potential to assist in the development of a deeper understanding of knowledge and increase knowledge retention [15].

Working together on tests and problem solving, in small groups of five or six students, provoked ongoing dialogue between group members, to gain consensus and build on each other’s individual knowledge. Students were dependent upon each other for their knowledge, which also fostered this collaborative learning. Vygotsky’s Zone of Proximal Development (ZDP) indicates the breadth and depth of learning possible by a student when provided with instruction [16].

Shared repertoire

Shared repertoire refers to the collective acquisition of shared language, resources, concepts, experiences and tools used and developed through interactions [11]. Throughout the course of the TBL sessions, students became familiar with the TBL teaching methods and resources. Self-directed learning within groups was still possible through established routines of pre-class reading, in class tests, receipt of feedback and completion of problem-solving activities. Students’ knowledge base was developed through their shared practices, such as the method used to construct the team’s pathophysiological flow chart.

The team test supported opportunities for students to explore and view knowledge in different ways, promoting self-reflection. Both the team test and clinical problem-solving activities made students reliant upon their collective experiences and understanding of knowledge, prompting critical reflection. Critical reflection is recognised as a method of analysing information to prepare for practice [17]. When an emphasis is placed on active learner involvement, students are encouraged to tackle problems together, in order to enhance the learning and reflection process [18]. Additionally, placing an emphasis on the basic sciences within a clinical context, has been shown to heighten interest and curiosity in the learner [8, 19]. In TBL, students reported that construction of their knowledge was assisted with provision of a relevant and authentic clinical context from experienced clinicians.

Study limitations

The results of this study are based only on perceptions of students and facilitators. Students and staff voluntarily took part in the focus groups and interviews, which may have biased our results. Their views may or may not be representative of the wider student or staff population, or applicable to other universities.

Conclusion

The socialisation, teaching and learning methods encouraged and entrenched in the strategies of team-based learning have been described using the communities of practice theoretical framework. The community of practice found in the TBL classes, and enhanced through the structure of TBL, provided an enriching and rewarding learning environment that motivated students to build on their basic knowledge and apply what had been learnt. Facilitators enjoyed the experience of helping students to construct their knowledge within the TBL framework, and social practice was developed. The interactions of experienced, senior clinicians as facilitators, sharing their expertise within a clinical context, prompted effective student engagement in learning and understanding. Our change in curriculum design and pedagogy will assist in preparing medical students for demands of the increasingly complex healthcare systems in which they will work. Future research investigations will utilise an ethnographic study design to provide a rich understanding of how students think and learn together within the TBL community of practice.