Many studies published in the past decade have shown the value of team-based learning (TBL) pedagogy, although it has been noted that more research is needed to clearly show its positive impact on learning outcomes [1]. Additionally, most TBL studies have been conducted in courses led by faculty, with minimal examination of student participation in faculty roles. Studies examining student participation in faculty roles involving course design and delivery have reported conflicting data on student satisfaction and learning outcomes [2]. Additional research in this area is warranted, and in the setting of TBL, it is particularly novel. Furthermore, the implementation of TBL involves limitations such as an increased workload and time constraints for the supervising faculty members [3]. It is important to note that research has indicated that students that can provide effective learning experiences to each other [3]. Exploring ways to deliver TBL courses with more student involvement may help alleviate faculty workload while maintaining a high-quality, satisfying student learning experience. This study aimed to assess student perceptions of an elective course with a TBL format, in which the students generated and delivered the majority of the content with faculty facilitation. We expected that by having a greater involvement in the delivery of the course, students would gain a better understanding of TBL pedagogy. Additionally, we hypothesized that student-generated TBL modules could potentially contribute to improving students’ self-perceived understanding of their assigned teaching topic, as well as their self-directed learning skills and overall satisfaction with the course.

In 2008, the California Northstate University College of Pharmacy was established, and was one of the first pharmacy programs to include a fully integrated TBL curriculum. The elective involved in this study was a two-credit hour course called ‘diabetes management and the ambulatory care setting.’ The course utilized both faculty and student-led TBL presentations throughout the curriculum to achieve student learning outcomes. When students were presenting TBL modules, faculty primarily served as facilitators to augment or clarify information. In addition, students performed a variety of specific active learning activities throughout the semester to help achieve student learning outcomes, including a patient simulation activity, patient interview exercises, and physical assessment labs. Students were also required to reflect on their class experiences by completing weekly journal entries and a final reflection paper. A summary of the course activities is provided in Table 1. An example of a rubric used in the course is shown in Appendix 1.

A major component of the course was the development and delivery of student-led TBL modules on a variety of topics related to diabetes mellitus. The first day of class included a faculty-led ‘how-to’ presentation on constructing TBL modules, which included a discussion of TBL background information, essential elements of TBL, Bloom’s taxonomy, techniques for building mini-lectures, and the construction of effective application exercises. The presentation was supplemented with time for discussion, in which student teams asked any questions that may not have been answered by the presentation. In order to evaluate student perceptions of student-led TBL, a questionnaire was administered and a focus group was conducted. All students enrolled in the elective were eligible to participate in the questionnaire. In addition, seven student volunteers participated in the focus group. The use of both questionnaires and focus groups allowed the investigators to obtain a more complete understanding of the students’ perspectives regarding student-led TBL.

A survey instrument was developed specifically for this study, containing nine four-point Likert-type items (Table 2). The items assessed the benefits and barriers that students perceived while creating their own TBL modules, as well as their perceptions of the impact that student-led TBL sessions had on their learning experience. A focus group guide was also developed (Table 3) to elicit specific examples of how having students lead TBL sessions affected their understanding of the topics covered during the elective.

Volunteer students anonymously completed the survey during the last day of classes. The focus group session was held a week after the final exam, and was moderated by an investigator not involved in the class in order to minimize bias. The focus group discussion lasted 45 minutes, was audio-recorded, and was transcribed verbatim for analysis. All focus group attendees received $5.00 gift cards. This study was approved by the California Northstate University College of Pharmacy Institutional Review Board.

The questionnaire responses were summarized as frequencies and percentages. Thematic analysis was conducted on the focus group data once accuracy of transcription was ensured. Two independent investigators (AH and VG) analyzed the focus group data and subsequently met to resolve discrepancies in the topics identified. Descriptions were generated in the relevant sections of the data (codes), and the descriptions were interpreted to identify major themes. Due to the exploratory nature of this study, themes were generated inductively. The focus group data analysis was conducted by hand, given the small amount of data.

A total of 30 students enrolled in the class, all of whom completed the questionnaire. Seventeen respondents were female. The results of the questionnaire responses are shown in Table 2. Fifty percent of the students agreed, and another 50% strongly agreed, that they would recommend this elective to another pharmacy student. More than 80% of the respondents agreed or strongly agreed that the class helped them better understand TBL pedagogy and improved their self-directed learning skills. While 76.6% of the students felt that generating the TBL modules helped them better understand the topic of the module, 62% felt that generating TBL modules resulted in too much extra work. Seventy-three percent of the students did not agree that they were more satisfied with student-led TBL modules. Still, less than a third of the respondents felt that the student-led TBL format was a barrier to achieve learning outcomes. Moreover, 96.7% of students agreed or strongly agreed that they achieved the student learning outcomes. Individual, team, and overall course grades were positive and indicated that students comprehended the content of the course. The average scores on the midterm examination and final examination were 83% (range, 66% to 94%) and 91% (range, 82% to 100%), respectively. The average course grade was 91%.

Four female and three male students volunteered to participate in the focus group discussion. Thematic analysis of the focus group data identified four common themes. The next sections describe these themes in detail with supporting quotes.

The objective of this study was to assess students’ perceptions of student-led TBL in an elective course, with the hypothesis that students would gain a better understanding of TBL pedagogy, as well as improving their self-perceived understanding of the assigned topics and their self-directed learning skills. While these objectives are certainly valuable in terms of achieving success in curricular outcomes, meeting these goals may have the added value of potentially reducing faculty workload in course development and in the classroom. Survey results suggested that this student-led TBL course helped improve students’ understanding of TBL pedagogy and their self-directed learning skills, as well as enhancing their understanding of the topics, thus achieving the goals of incorporating student-led TBL into the classroom. The survey results showed that the majority of students felt that they understood TBL pedagogy better and gained a deeper understanding of the topics. Performing TBL compels students to gain mastery of basic content in order to teach their peers higher-level applications, which may translate into a deeper understanding of various topics. The majority of students also felt that they improved their learning skills, which may have been because TBL requires a higher level of organization prior to implementation.

While our study did not specifically measure the impact of student-led TBL on faculty workload in the classroom, one could speculate that there is potential for student-led TBL to have a positive impact on the time spent on building modules and preparing for classroom teaching. In our elective, while faculty continued to provide support regarding the identification of key topics, required readings, and individualized readiness assurance test questions, the students were responsible for background research in addition to the readings provided and the generation of learning objectives, mini-lectures, and application exercises, which substantially reduced the workload of the course coordinators. This was somewhat compensated for by the faculty time required to effectively review student-generated content before delivery, although the workload was reduced overall. Students identified the most beneficial parts of the course, as well as the most significant challenges. In the focus group, the students agreed that incorporating the simulation activity into the course provided them with a valuable hands-on learning experience. Multiple previous studies evaluating the inclusion of a patient simulation component in courses have established the value of such exercises in improving student empathy, which is consistent with the results of our study [4-6]. The focus group results also showed that students identified time constraints in delivering their TBL modules and their overall workload as their biggest challenges. The authors allotted one hour of each two-hour class for student groups to present their modules, and students consistently noted that they felt rushed in delivering their material, especially their application exercises.

The focus group participants also reported that another challenging aspect of the course was creating TBL applications. These exercises are an essential component of TBL, designed to foster higher-level critical thinking and team problem solving [7]. The focus group participants also experienced difficulties in identifying the most important concepts to extract from the assigned readings in order to build effective learning objectives. They experienced a similar difficulty in creating the applications due to their limited experience in applying clinical information. Moreover, students noted their preference to have faculty input during these processes and to have faculty members review important material to help ensure that learning outcomes were met.

The results of our research were similar to the results that have been reported for other peer-to-peer models of teaching [8]. A previous study has found that peer-to-peer teaching allowed students to better perceive the challenges that other students face when learning and to provide better feedback. Moreover, perceptions regarding decision-making dynamics and group support have been reported to be more positive in student-led groups compared to faculty-led groups [8]. In addition, the students perceived improvements in their interpersonal communication, presentation, teamwork, leadership, and evaluation skills, which are all essential for future pharmacy graduates to function as a cohesive team in a wide range of healthcare fields and to provide the most competent care to patients.

The results of this study should be interpreted in light of its limitations. While the study suggests that student-led TBL contributed to positive student perceptions relating to understanding and satisfaction, without a comparator group, the authors cannot conclude that the TBL pedagogy was solely responsible for these observations. Second, the focus group included students who had completed the survey assessing their perceptions regarding student-led TBL, which could have influenced their responses. Selection bias should also be considered, since the focus group participants were volunteers and may not have represented the views of the entire class. As we did not anticipate the challenges associated with the development of application exercises, information was only acquired about this issue through the focus group. Future questionnaires should include this dimension in order to ascertain whether a comprehensive discussion illustrating how to create valuable application exercises would improve students’ understanding of how to create complete TBL modules. In addition, future focus groups should inquire about how students approach the development of applications, as well as identifying the resources that students used and whether they modeled their applications on those that they had previously seen in the classroom. Finally, the sample size for the survey was small. Therefore, it may be difficult to generalize the results of this study widely.

Moreover, while peer-to-peer teaching in academia is relatively well studied, its use within TBL pedagogy itself is novel; however, more robust studies are needed to shed light on the connection between student-led TBL and improvements in learning, understanding, and satisfaction. This pilot study suggests that students may perceive student-led TBL positively, and that further studies are warranted.