What is one way to ensure that students are absorbing three hours worth of information? Have them study the material before coming to class then come to class and take both individual and group exams. The flipped classroom isn’t a new model of teaching, but it’s becoming one that more educators are using. James “Frank” Titch, DNP, CRNA, RN, associate professor in the Nurse Anesthesia program at Duke University School of Nursing (DUSON), has been using a team-based learning model for more than a year to flip his classrooms, and it’s come with great benefits for him and his students.
The flipped classroom is a pedagogical model in which the typical lecture and homework elements of a course are reversed. This model of teaching and learning became interesting to Titch when he began work for his Duke School of Nursing Institute for Educational Excellence Teaching Fellowship. His work focused on the use of team-based learning in a series of his nurse anesthesia courses.
“I used the model outlined by Dr. Larry K. Michaelsen, who’s the leader in the design and use of the team-based learning strategy,” said Titch. “As I began to learn more about this model of educating, it compelled me to reevaluate how I’ve been teaching for years.”
Titch adds: “Prior to my work with the teaching fellowship, I lectured students for two hours or more. But team-based learning encourages active learning. Students just can’t process large amounts of information by just sitting in a classroom and listening to the professor for hours, then memorizing content and recalling it for an exam. Learning shouldn’t be a spectator sport; otherwise students don’t know what to do with the information.”
With this new information in hand, Titch didn’t wait to implement this innovative approach to evidence-based teaching; he immediately changed the format of his courses. He transformed his courses from a teacher-centered, lecture-dominated environment into a student-centered, team-based setting. Titch’s students, who have courses with him over a year period in the nurse anesthesia program, were hesitant at first. After all, most group work ends up with one or two carrying the weight of the work while others skate through. However, Titch’s format, which includes peer evaluation, requires each student to give equal input as part of the course grade.
In the School’s online learning platform Titch has developed a structured “one-stop shopping” that provides students with all of the materials for each class. He also creates discussion forums to stimulate critical thinking, which all students are expected to comment on and correct one another as needed. Once the students return to class, they take an individual test on the key ideas from the pre-class assignment. Once the individual tests are completed and turned in, the students get into their groups and retake the test as a group by coming to consensus on their answers.
The before and after view the classroom takes on when the students transition from individual test takers to group test takers is intriguing to watch according to Titch. “You could hear a pin drop; it’s so quiet in the room when the students are taking their individual tests. And you can tell when someone might be having a tough time with a question by the expression on their face. However, when it’s time for the group test, the room comes alive. There are passionate discussions all across the room as these students are teaching and learning from each other. This type of collaborative and social environment prepares them to work in interprofessional health care environments.”
For the group exam, students are provided with special scratch-off score sheets called an Immediate Feedback Assessment Technique for their tests. For each test question, the students have to scratch off the correct answer. The more they scratch off to get to the correct answer, the more points they lose. This type of answer sheet provides the students with real-time feedback and according to Michaelson’s research encourages group discussion and also provides partial credit for partial knowledge. Students are also given a chance to challenge test questions with valid arguments and then write evidence-based appeals. Final grades are determined by how great they do on both the individual and team exam.
After the group test is complete, Titch provides the students with a case study related to the care of an anesthesia patient. In their groups, the students work to develop an anesthetic plan for that patient. All of the plans are posted around the classroom, and each group uses Post-It® notes to comment on the plans developed by each of the groups. This activity allows students to continue collaborating while applying the concepts from the pre-class material. Students analyze the content, compare it, deal with ambiguities and uncertainties, make meaning of it, and create new perspectives.
Even when they are having discussions regarding test questions or care plans for patients, Titch does not enter the conversations. “It’s important that they become confident in the material so they are comfortable in their clinical environments. Instead, I facilitate the discussions and encourage them to find and work together to come up with the best answer.”
Prior to the end of class, Titch will use common themes from the individual tests and/or discussions to clarify any misunderstandings or lingering questions.
Benefits of Team-based Learning
Titch explains that while the work to build this type of environment is phenomenal, for faculty who are passionate about teaching the outcomes will be individually satisfying. In Michaelsen’s research, he recognizes that faculty members today are confronted with multiple, often conflicting demands from various constituents such as securing grant funds to ensure financial sustainability, teaching larger classes and increasing effective teaching to ensure student course satisfaction and increased enrollment.
Nonetheless, outside of the time it will take to initially set up the active classroom environment with pre-class materials, team-based learning was developed to shift the focus of instruction away from the teacher dispensing information and places the responsibility on the students to actively engage.
“I must admit when you’re expected to focus on multiple areas as part of your role as faculty, initially there is a chance that something will fall to the wayside as you focus your energy on setting up this learning environment,” Titch explained. “However, as educators we are here to teach our students so that they are adequately prepared in their health care specialties, and it’s what they are paying for as well. Personally, team-based learning has eliminated the time commitment I used to need in order to grade exams and schedule exam reviews.”
Titch admits that the new learning environment helped to strengthen a skill he didn’t have to really use before. “With this learning experience, I’ve had to strengthen my facilitation skills,” he said. “Thankfully, I’ve had mentors such as my Duke University colleagues from across the institution who already implemented this type of learning environment, and they were able to help guide my process.”
The benefit isn’t just for faculty. Research shows that students who participate in team-based learning courses have a deeper understanding of the concepts, a sense of responsibility to and for their teammates, a genuine appreciation of the power of team interaction, ethical decision making skills and even improved work performance.
As for Titch’s students, since moving to the use of team-based learning they score well on examinations, are more engaged in classroom discussions, raise more thoughtful and insightful questions about the material, and are effectively co-learning with each other.
“I’ve noticed that my students are more relaxed,” Titch said. “In this learning environment I’ve relinquished control as faculty versus student, and with me facilitating instead of lecturing it creates an environment where students are able to see themselves as professionals. While I'm still the expert in the room, students no longer feel as though they are being treated as students, but as peers.”
Titch’s love for teaching and his passion for seeing his students reach their fullest potential as nurse anesthetists are apparent in conversations with him. “Had I not applied for this teaching fellowship, I don’t know that I would have been exposed to this type of teaching. And to be able to instantly see the results of engaging my students in learning and enriching their outcomes is its own reward.”