INTRODUCTION

The current scenario of higher education in health has brought new challenges and inspired profound transformations to meet the evolutionary changes in student training¹. In this sense, the National Curricular Guidelines (DCN, Diretrizes Curriculares Nacionais)^2),(3 for undergraduate courses in Medicine and Nursing recommend active methodologies (AM) as an educational strategy to develop competences and abilities in the training of health professionals. The AM emerged in the 1980s, in contrast to the content transmission model represented by the figure of the “aulista teacher” (i.e,. one that only explains the topics of the classes), configuring itself as an alternative to passive learning, which requires proactivity and participation from students to carry out the activities⁴.

In AM, the teaching-learning process starts with a problem situation, which provides critical reflection, mobilizing the student to search for knowledge, aimed at solving it. Such mobilization encourages new reflections and the proposition of appropriate solutions, increasingly bringing theoretical and practical reasoning closer together^5),(6. With a student-centered approach, AM encourage their autonomy and self-regulation as protagonists in the construction of knowledge^4),(7, removing them from the comfort zone generated by the traditional teaching model and calling on them to be responsible for their learning process, which may explain why the perception of the student body is not unanimous regarding their preference for this type of methodological strategy, when compared to the traditional methodologies^8),(9.

Currently, one of the AM used in higher education institutions (HEIs) in health is Team-Based Learning (TBL), whose theoretical basis is constructivism, prioritizing horizontal relationships in the teaching-learning process, of which the teacher is a facilitator. The students’ previous repertoire is valued in their cognitive construction, providing significant learning and awareness of this process (metacognition), combined with the development of skills related to initiative, decision-making and clinical reasoning^10),(11. The interaction between peers (student-student) allows them to develop communication and collaborative work skills, which are also characteristic demands of health services and contemplate the Brazilian DCN^{2),(3),(12)-(16}.

Studies show that student learning in TBL depends on factors such as the structuring format of the course, with class division into small groups^17),(18 and the type of covered content, which is based on problem situations^19,20. Regarding student characteristics (such as behavioral profiles and study skills), previous research shows that this factor does not have a significant impact on learning in a TBL environment, although introverted students prefer the traditional teaching method to the detriment of TBL^21)-(23. Despite this, another study suggests that this learning can be affected by the students’ introversion or extroversion profile^24),(25.

In 2020, during the context of the coronavirus disease 2019 (COVID-19) pandemic, a change in Brazilian legislation²⁶ determined that educational institutions would temporarily switch in-person classes by digital ones. Thus, the TBL method, traditionally applied in-person, started to be implemented by some HEIs as emergency remote teaching (ERT)^27),(28. In this study, the term “synchronous online teaching” was adopted as corresponding to ERT.

In the maximum attempt to reproduce the principles of in-person teaching in the virtual environment, in accordance with the guidelines of the Team-Based Learning Collaborative (TBLC)²⁹, it was necessary to adapt, from teaching strategies to the implementation of digital platforms, which led to challenges , both to the students’ school experience and to the teaching practice³⁰. Despite the efforts, online learning brings with it a stigma of lower quality when compared to in-person learning³¹. However, in a comparative study involving 427 students and carried out in the pandemic context, online TBL sessions were evaluated as positively as in-person sessions³². Another study on teaching during the COVID-19 pandemic, also comparing in-person and online modalities of TBL, showed that synchronous online sessions can offer a demonstrable benefit to students³³.

In both in-person and online TBL, each main topic (“macro unit”) to be worked on in a module is covered in three phases: 1. previous preparation; 2. preparation assurance; 3. application of concepts³⁴. The two modalities differ regarding the way the second and third phases are carried out, when the proposed clinical cases are resolved collectively, with the presence of everyone in the classroom, whether physical or virtual.

Based on these considerations, this study aimed to evaluate the perception of healthcare undergraduate students about online TBL and analyze whether there is a difference regarding its perception between groups of students with different levels of exposure prior to in-person and online sessions of the method, in addition to verifying whether such perception can be affected by the student’s behavioral profile.

METHOD

The present study was carried out from September to December 2021, at Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), encompassing undergraduate courses in Medicine and Nursing. The first was offered in 2016 with TBL already implemented, the year in which the institution started to systematically employ the method in its undergraduate courses. The second operated with the traditional teaching method for 26 years, until the introduction of TBL in 2015. The implementation of the method has institutional support, both in terms of personnel, infrastructure and technological support, which has intensified since 2020, with the need to migrate to the synchronous online mode and consequent use of online classrooms on the Zoom ^® platform, replacing FICSAE physical classrooms. The specificities of applying the in-person and online modalities are described in Chart 1.

It is worth emphasizing that, in the aforementioned experience of transposing the in-person TBL to the synchronous online modality, the time allocated to each phase was maintained from one modality to the other, as shown in Chart 1. Moreover, the materials selected for the previous preparation remained the same, both in format and content, since phase 1 of the TBL is originally configured for pre-class and online individual study. Another element that was not changed was the type of questions that made up the following phases, with the more direct exercises being maintained in the individual and team tests in phase 2, and the resolution of cases in phase 3.

RESULTS

The study sample consisted of 241 students, 44% of whom were undergraduate students of Medicine and 56% of Nursing, with a predominance of females (81%), aged between 20.8 and 24.4 years. Still regarding the sample profile, the participants’ level of exposure to in-person and online TBL modalities was investigated up to the moment of data collection. Most students had participated in more than 10 in-person TBL sessions (90%). Regarding participation in online TBL sessions, there was a balance between classes in the total sample: 47% of undergraduate students had participated in 1 to 10 sessions and 53% had participated in more than 10 sessions.

Regarding the answers to the APA-TBL instrument, in the dimension “team influence on individual performance”, the highest favorability index was found in item Q24 (95%), with this being the maximum percentage also in relation to the results of the other APA-TBL dimensions. Although the other items in this dimension do not have such high levels of positive perception, students’ favorability towards the method was observed, since only one (Q14, 74%) of its 11 questions was below the established limit of 75% in the sum of the answers from the “I totally agree” and “I agree” classes (Graph 1).

Graph 1 Percentages of responses to the “team influence on individual performance” dimension of the APA-TBL instrument. 

In the dimension “teacher’s performance/role in applying the method”, items Q2 and Q3 had the lowest favorability rates, in descending order, with both having less than 75% of respondents indicating “I totally agree” or “I agree” (Graph 2).

Graph 2 Percentages of responses in the “teacher’s performance/role in applying the method” dimension of the APA-TBL instrument. 

A high rate of favorability in relation to the method was also observed in the “student commitment” dimension, in which all questions had more than 85% of respondents indicating “I totally agree” and “I agree” (Graph 3).

Graph 3 Percentages of responses to the “student commitment” dimension of the APA-TBL instrument. 

In the “team responsibility and performance” dimension, item Q16 had the lowest favorability index (43%), followed by items Q7, Q10 and Q17, in descending order. Item Q9 was the only one to attain more than 75% in the sum of responses in the “I totally agree” or “I agree” classes (Graph 4).

Graph 4 Percentages of responses to the “team responsibility and performance” dimension of the APA-TBL instrument. 

To analyze the results related to the four dimensions of the APA-TBL, scores were generated for each of them. As these scores did not follow a normal distribution, the preferred descriptive measure for data interpretation were the median value and quartiles (1^st and 3^rd). The dimensions had very similar medians, with values between 3.8 (for “team responsibility and performance” dimension) and 4.3 (for the “student commitment” dimension), as well as the quartiles. Moreover, all dimensions showed downward discrepant values, that is, greater concentration in higher scores.

The APA-TBL dimension scores were compared regarding the number of students’ participation at in-person TBL sessions and online sessions (whether “of 1 to 10 sessions” or “more than 10”). The students who participated in more in-person TBL sessions (n = 186) showed a more negative perception of the teacher’s performance in online TBL when compared to those who had participated in fewer in-person TBL sessions (n = 19), with the score values in 1^st and 3^rd quartiles of students participating in more than 10 sessions (4.0 [3.5-4.3]) lower than those of students with 1 to 10 sessions (4.0 [4.0-4.5] ), p-value = 0.039.

Of the four dimensions that comprise the APA-TBL instrument, in three of them the tests showed statistical significance among students who had participated in 1 to 10 sessions (n = 96) and more than 10 online TBL sessions (n = 106). The median score and interquartile range values of the group more exposed to the method were lower than those of the less exposed one: 3.8 [3.5-4] and 4 [3.8-4.5], p-value = 0.001 (“teacher’s performance/role in applying the method”); 4.3 [3.8-4.5] and 4.3 [4-4.8], p-value = 0.028 (“student engagement”); 3.6 [3.0-4.0] and 3.8 [3.4-4.2], p-value = 0.042 (“team responsibility and performance”). Students who participated in more than 10 online TBL sessions had a more negative perception regarding the teacher’s performance in applying the method, student commitment and team responsibility and performance when compared to the perception of those who participated in less than 10 TBL sessions. online.

The results obtained from the 108 respondents of the DISC instrument were grouped around the four most prevalent behavioral factors among students: dominance (D), influence (I), submission (S) and compliance (C).

The main behavioral profile found was type “S”, corresponding to 38% of students. The individual with submission highlighted in their behavior has, as main descriptors, the ability to be a good listener, patient, sincere, constant and a team member, being a relevant element and showing the possibility of having difficulties in demonstrating their emotions³⁶.

“I” was seen as the second behavioral profile, represented by 31% of respondents. Influence can indicate someone’s ability to deal with people and influence them, with this ability being greater the higher this behavioral profile was. The main descriptors are confident, inspiring, popular and sociable behavior, with optimism generally being a markedly present emotion³⁶.

The third profile found was “C”, corresponding to 24% of study participants who answered the DISC questionnaire. People with prevalent compliance are focused on dealing better with rules and procedures established by others, having, as their main behavior descriptors, more precise skills in relation to analysis and perfectionism, and demonstrating more careful and detailed behaviors. In this behavioral profile, the fear of making mistakes is a possibly frequent emotion³⁶.

The least prevalent profile among the 108 DISC Test respondents was “D”, corresponding to 7% of students. The prevalent dominance in behavior indicates that the person has greater ability to deal with problems and challenges, with the main descriptors of their behavior being competitiveness, decision-making capacity, objectivity and focus on results. They generally have the emotion of anger as a driver of their capacity to solve problems³⁶.

These four DISC groups were compared in relation to the APA-TBL dimension scores and did not show any statistical difference (p-value > 0.05).

Based on the results found in this study, an instructional material in digital format entitled “Recommendations for applying Team-Based Learning in the online modality” was prepared, whose PDF file is available for free access and download at the link https://tinyurl.com/comoaplicartblonline.

DISCUSSION

In the present study, students from the participating undergraduate Medicine and Nursing courses showed a favorable perception regarding online TBL, since only seven of the 24 APA-TBL questions had less than 75% of respondents indicating “I agree “ or “I totally agree.” This observed favorability corroborates a recent study on the effectiveness of online TBL, in which more than 80% of the students perceived the sessions as being pleasant and beneficial to active participation and engagement in group discussions⁴⁵. Another study also on the application of online TBL during the pandemic period showed a positive influence of the online mode on the students’ responsibility, who preferred it to the in-person modality⁴⁶.

The highest favorability index (Q24, 95%) found in the study is related to the idea that team learning benefits the future professional, showing that most participants recognize the importance of collaboration in healthcare professions, as stated in previous studies^15),(16.

The positive perception in 10 of the 11 questions in the “team influence on individual performance” dimension showed students’ favorability towards the method. This finding corroborates a study that showed an improvement in students’ individual performance based on teamwork developed in online TBL⁴⁶.

Two of the APA-TBL questions that showed a favorability ratio lower than the established limit are in the dimension “teacher’s performance/role in applying the method” (Q2, 51%; Q3, 70%). Another four questions belong to the “team responsibility and performance” dimension: Q7 (60%); Q10 (62%); Q16 (43%); and Q17 (70%). It is worth highlighting, however, that items Q2, Q3 and Q16 are related to actions that are independent of the TBL modality, whether in-person or online, as the stages of selection and provision of content by the teacher occur prior to the TBL session, as well as the selection of teams, which is carried out at the beginning of each semester and does not change throughout the period. Therefore, this finding does not seem to represent a specific deficiency of online TBL. This result confirms a previous study on the importance of the administrative aspect present in the role played by the teacher in online TBL, planning the sessions and defining the composition of the groups, among other functions that are required for the satisfactory development of the course⁴⁷.

The lower favorability result also obtained in items Q7, Q10, Q14 and Q17 may be related to the synchronous online modality of TBL sessions that took place during the COVID-19 pandemic, since group participation may have been affected by the specificities of the interactive dynamics in the virtual environment. In this sense, once again, the role of the teacher organizing the online rooms, managing the interaction mechanisms in them and clarifying the rules that regulate the online TBL sessions is relevant⁴⁷.

The lowest favorability index in the entire study was found in item Q16 (43%), which concerns the composition of online TBL discussion teams, therefore highlighting the relevance of student-student interaction in the perception of the method, which, together with the student’s interactions with the teacher and with teaching materials and resources, constitutes the collaborative environment of active methodologies⁴. Also in this sense, the results showed that item Q11 had 88% of responses “I agree” and “I totally agree”. In other words, the students seem to have prepared adequately, but they realize that their contribution to the group, during the synchronous online TBL session, could have been greater, as indicated by the responses to items Q7 and Q10, previously discussed.

One factor that may have impacted this perception is the limitations of interaction in the digital environment between members of the same group. A recent study carried out in a distance learning (EaD, Educação à Distância) course identified that, although students are aware that interaction is important and that help from colleagues contributes to their learning, they are not always able to satisfactorily engage in these relationships⁴⁸. Moreover, the findings of this study confirm how important the collaborative aspect is in organizing online rooms and managing groups in TBL synchronous online sessions. Since virtual learning environments are not collaborative in nature, these tasks are the responsibility of the teacher, who takes on this extra challenge in order to encourage student participation and interaction between them⁴⁷.

It is also up to the teacher to pay attention to their interaction with students, a prominent factor in the complex and multifactorial process that constitutes learning⁴⁹. In an in-person TBL session, students and teachers share the same physical space, which allows the teacher to interact frequently with the groups, encouraging the members’ engagement in solving the issues and, mainly, the assessed case. In online TBL, however, to interact with the groups, the teacher needs to virtually enter and leave the online rooms in which the discussions take place, which imposes spatial-temporal differences that need to be assimilated by both the teacher leading the session and the students.

In addition to these limitations regarding the way of interacting with students, teaching practice in the digital environment resulted in a need for abrupt adaptation by teachers, who were forced to use technology in teaching and deal with the difficulties found in handling these new tools. An integrative review study that analyzed the implementation of online learning from the perspective of the medical educator concluded that teachers require strong institutional support, with detailed guidance on how to implement the technological devices in question. There was also a strong need for collaboration between teachers for the more cohesive development of online teaching⁵⁰.

The students’ perception of online TBL was analyzed in relation to their level of exposure prior to in-person and online TBL sessions. Students exposed to more than 10 in-person TBL sessions had a significantly more negative perception in the dimension “teacher’s performance/role in applying the method”, compared to less exposed students, who participated in 1 to 10 sessions. This finding indicates that the mediation performed by the teacher in online sessions seems to have been insufficient in the students’ perception with prolonged exposure to in-person TBL.

The frequency of participation in online TBL sessions also resulted in a significantly more negative perception in this same dimension, in addition to the “student commitment” and “team responsibility and performance” dimensions. In other words, prolonged exposure to online TBL seems to have negatively impacted the students’ perception of the method. Although a previously mentioned recent study concluded that online TBL is effective for the teaching-learning process⁴⁵, it is worth highlighting that the aforementioned finding of the present study can be justified by the physical and cognitive strain caused by factors such as excessive screen time (both in pre-class study, as well as during online sessions) and a constant state of readiness required for interaction mediated by digital tools.

Therefore, it is possible to observe the effectiveness of this teaching method and the importance of alternating its application in the in-person and online modalities, with diversification of teaching resources, in order to prevent student exhaustion due to technologically mediated teaching.

With the attenuation of the pandemic context, in July 2022, the National Education Council (CNE, Conselho Nacional de Educação) decided in favor of approving the “General National Guidelines for the development of the hybrid teaching and learning process in Higher Education” (Opinion CNE/CP n. 14 /2022), considering that, due to the exceptional situation created by the new coronavirus, the search for new ways to reorganize the teaching and learning dynamics in Brazilian higher education institutions was accelerated. For the CNE, the flexible conception of the teaching-learning process, mixing in-person and online activities, through the use of digital technologies, was made possible by the increasing connectivity, bringing new demands to higher education.

Furthermore, according to the council’s opinion, the development of studies, research, experiments and innovations related to hybrid education underway throughout the country could bring valuable contributions to its consolidation⁵¹. This document was approved by MEC Ordinance n. 558, of August 2, 2022, highlighting the value of the online modality, even though the need to carry out educational activities at home has ended⁵². Thus, the new pedagogical approach advocates, by definition, the student’s leading role in the teaching-learning process, with the teacher acting as an advisor, monitor and mentor, just as TBL is configured, which proves to be an appropriate and interesting method to be incorporated in this current context of hybrid education.

Regarding the mapping of the behavioral profile of the participants in the present study, data collection with the DISC Test showed a smaller number of respondents (n = 108), when compared to the number of APA-TBL respondents (n = 241), possibly because it was sent to students only after filling out the TCLE and APA-TBL online on the REDCap ^® platform, in which it cannot be included like other questionnaires and terms due to the agreement signed with the instrument’s developer.

When comparing the different behavioral profiles of the participants with the perceptions of the four dimensions of the APA-TBL, these did not show results with statistical significance (p-value > 0.05). Thus, it was demonstrated that the DISC factors of student behavior did not influence the evaluation of the assessed method.

As limitations of the study, it is highlighted that it was not possible to compare the results obtained with previous studies whose objective was the evaluation of in-person TBL. Moreover, due to the non-probabilistic convenience sampling technique used in the study, the calculation of representativeness of the samples cannot be carried out, and it is only feasible to determine the minimum effect size detectable for each obtained sample. On the other hand, the interference of the level of participation in online sessions on the students’ perception of the method must be highlighted. The relevance of studies like this lies in the fact that knowing how students evaluate the method allows teachers and educational managers to meet student demands regarding the application of TBL online and the structuring of the course and its human, pedagogical and technological resources⁵³.

CONCLUSIONS

The present study showed a favorable perception of health undergraduate students about online TBL in 17 of the 24 APA-TBL questions. Students exposed to more than 10 online TBL sessions had a significantly more negative perception in three of the four APA-TBL dimensions, when compared to those with less exposure. The group that had participated in more than 10 in-person TBL sessions showed a significantly more negative perception in just one dimension of the instrument, when compared to that less exposed. Moreover, the study showed that there was no correlation between the student’s behavioral profile and their perception of online TBL.