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Faculty as Learners

Factors Influencing Implementation of Team-Based Learning in Health Sciences Education

Thompson, Britta M.; Schneider, Virginia F.; Haidet, Paul; Perkowski, Linda C.; Richards, Boyd F.

Section Editor(s): Mechaber, Alex MD; Skeff, Kelley MD, PhD

Author Information
doi: 10.1097/ACM.0b013e3181405f15
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Team-based learning (TBL) is an instructional strategy that is used to foster active learning within a large-group setting. It can be conducted with limited faculty. The processes of TBL are well-described elsewhere1,2 and include three distinct phases. In Phase I, students study assigned materials outside of class (textbook, lecture videos). During Phase II, students take readiness assurance tests, first as individuals and then in assigned groups scattered throughout a lecture hall. These tests are designed to hold learners accountable for Phase I preparation and to foster peer-to-peer teaching in areas of deficiency. In Phase III, students reconvene in assigned teams and hold intra- and intergroup discussions to identify and defend solutions to complex application problems. In a typical TBL course, students remain in their assigned teams for the duration of the course and progressively become more effective in helping members master and apply course content.

Studies suggest that TBL is associated with positive learning outcomes. TBL has been correlated with increased learner engagement and preparedness,3–6 improved problem-solving skills,7 better communication processes and teamwork skills,4,8 and improved knowledge outcomes.4,9 Although the processes of TBL have been described, adequate work has yet to document the relative impact of contextual factors that tend to facilitate or impede the implementation and maintenance of TBL. We previously described overall factors (faculty, administration/curriculum, students, and course) associated with TBL use at 10 initial schools. Having noted an increase in the use of TBL throughout the health sciences community, we were interested in analyzing the contextual factors related to implementation of TBL of additional individuals to confirm and extend our previous work. Using the framework of Diffusion of Innovations,10,11 we were specifically interested in identifying the context, or the characteristics (either facilitators or barriers) of the environment or system, that encourage or discourage use of TBL.

The purpose of our study was to identify the context factors associated with the success or failure of TBL implementation and to contribute useful insights using existing diffusion literature to benefit individuals involved in other innovations in the health sciences.


Questionnaire development and administration

In concert with the preparation of a final report for a grant to disseminate TBL (Fund for Improvement of Post Secondary Education #P116B010948), we developed a 16-item questionnaire to document the degree and conditions surrounding TBL dissemination throughout the health sciences educational community. Three of the 16 items on the questionnaire were the following open-ended questions: “Briefly describe your impressions of the value and viability, if any, of team-based learning in your educational setting,” “List three of the most important factors that facilitate use of team-based learning,” and “List three of the most important factors that impede use of team-based learning.” Our results are based on these open-ended questions. The remaining 13 items asked participants to identify demographic and background information such as the specific elements of TBL they used and participant’s academic rank. Results from these items are not presented in this paper. We first administered the questionnaire to three faculty who used TBL at three different health sciences programs to establish face validity. When then launched the questionnaire to the larger community of health science educators exposed to TBL. We administered the questionnaire July 2006 via the Web and sent three follow-up e-mail reminders at approximately 1 week, 1 month, and 2 months.


We identified individuals (n = 703) who had attended workshops or presentations on TBL and who had provided their contact information, including e-mail address, for inclusion on a national TBL database. From the database, we identified 594 valid e-mail addresses. In total, 297 individuals responded to the questionnaire (297/594, response rate = 50%) representing 73 health sciences programs throughout the country. Ninety-five respondents had not implemented TBL, 123 were in the early stages of implementation (TBL used it in at least one instructional setting), and 70 were in the later stages of implementation (TBL used on a routine basis). Nine did not indicate their TBL use. Because the purpose of our study was to capture the perceptions of actual TBL users and learn from their experiences implementing TBL, we chose to include only the 193 who had implemented TBL.

Data analysis

We used the constant comparative method with two authors (V.F.S., B.M.T.) to analyze the open-ended comments.12,13 We coded comments into 899 units, units into categories, and categories into themes or factors. Our agreement (V.F.S., B.M.T.) on the coding of units was 83.3%; we reached consensus on all coding disagreements with four iterations of review and discussion. We also coded each comment as positively or negatively impacting implementation of TBL. We enhanced our internal validity through triangulation (multiple investigators) and peer examination with the other authors on multiple occasions during the coding process.12 Once we had completed the coding process, we counted the number of comments for each factor as well as the number of comments that were expressed in positive or negative terms within each factor. We conducted this study with oversight from the institutional review board at Baylor College of Medicine.


Our analysis of the three open-ended questions revealed five factors, listed here in rank order by number of respondents indicating the factor: buy-in, resources, expertise, time, and course characteristics (see Table 1).

Table 1
Table 1:
Factors Identified as Vital to TBL Use by Participants Who had Implemented the Method (n = 193)


Approximately 60% of the respondents (n = 115) commented on the importance of buy-in from faculty, students, and the administration. Buy-in from faculty included their “willingness,” “interest,” “enthusiasm,” and/or “resistance to new methods.” One respondent commented that they had “faculty who are very enthusiastic about using the teaching strategy and a group of residents who enjoy the experience very much as it forces them to apply material in a variety of contexts.” Another indicated that “it can be difficult to get past faculty skepticism about the approach….” Although buy-in from faculty was vital, respondents also identified buy-in from students as important, describing student buy-in as openness, receptive, willing to change methods, resistant to new methods, or cooperation. At the administration level, buy-in from a dean or upper-level administrator was another key to success.


Faculty expertise was identified by 38% (n = 73) of the respondents. Expertise was garnered through initial and ongoing training (both at the national and school level), mentoring from other colleagues experienced in the method (both within and outside the college), and personal experience with the method. One participant wrote:

TBL … takes skill/ practice on the part of the educator to “get [it] right.” It requires a greater level of sophistication and clarity (i.e., understanding … what do I need to teach and why am I teaching it) than does picking out which PowerPoints best illustrate course information.


Resources were identified by 37% of the respondents (n = 72). Space was an important resource, specifically a large and properly configured classroom to conduct TBL sessions. In addition, respondents felt that a case bank of readiness assurance test questions and application exercises, along with a good textbook for student independent study, was beneficial. One individual wrote,

Students consider TBL increases their learning more than traditional small groups [student evaluation comments]. Students and faculty consider the students are working better with their peers after a semester of TBL. Problems with continuation of TBL work include … availability of rooms large enough for TBL and having good seating arrangements and adequate sound proofing to allow for easy and effective group interaction and communication.

Other resources that were correlated with positive or negative TBL outcomes included personnel support for assigning groups and entering/calculating grades, availability of faculty to conduct the sessions, and proper equipment and supplies (such as an audience response system).


Thirty-six percent (n = 70) of the respondents commented on time, particularly at the onset, to develop TBL materials. One respondent indicated that TBL was a “heavy load up front to develop cases and IRATS [individual readiness assurance tests].” Another respondent indicated that it was “time-consuming to prepare the first time, but effective and well received.” Time within the curriculum was also identified as important, such as having longer class periods and time flexibility.

Course characteristics

Lastly, course characteristics were mentioned by approximately 16% of respondents (n = 30). The size of the course was an important issue to some respondents, with larger courses harder to manage. One individual wrote, “The value [of TBL] is high. The viability is more problematic … My experience has primarily [been] with groups of 25 … five teams of five students each. I found this size to be very effective….” Additionally, content of a course could either positively or negatively facilitate use of TBL. One respondent commented that “not all subjects lend themselves to TBL,” whereas another indicated that content “focused on strategy rather than facts” was positively correlated with use.

Negative or positive facilitators of TBL

At the outset of our analysis, we assumed based on early studies4,5 that the factors we identified would have both positive and negative influences. Our results supported this assumption. As indicated in Table 1, respondents’ comments about buy-in and resources were approximately equally distributed in the negative and positive direction. The absence of buy-in was negative; presence was associated with positive outcomes. The same was true regarding resources. Comments regarding expertise and course characteristics tended to show similar trends, with a few more positive comments associated with expertise and course characteristics. Interestingly, a majority of comments regarding time were negative.


Our results confirm and extend our earlier studies which were based on a limited number of early adopters of the method.4,5 While our results are specific to TBL, they have implications for other educational innovations introduced into health sciences education. Using the diffusion of innovation theory, the factors we identified seemed to influence the fit between the innovation (TBL) and the user (faculty). Interestingly, buy-in was most often mentioned as a facilitator or impediment to the use of TBL, indicating that this is a vital factor for those implementing TBL. In addition, our study found that time, expertise, resources, and course characteristics were also important factors.

Although our results included educators from across the country, our study was based on health science educators who had implemented TBL. In addition, our sample included only those individuals who had provided their contact information after attending training. Therefore, although our data are representative of a cross-section of schools, they are representative only of those who had implemented TBL, had an available e-mail address, and chose to respond to the survey.

Our results suggest that more research is needed to better understand factors that may influence the choice not to adopt TBL. In addition, research should explore “best practices” for optimizing buy-in, expertise, resources, time, and course characteristics within an educational context.

As health science faculty and administrators consider the fit of TBL or other educational innovations within their setting; buy-in, especially from the faculty; time at the outset; development and availability of expertise; resources, such as appropriate classroom space; and course characteristics, such as course content, are important factors to address. More research is needed to identify how faculty address these factors and overcome barriers or negative influences associated with each (i.e., limitations in faculty buy-in, time, expertise, resources, and course content).


This research was supported in part through a grant from the Fund for Improvement of Post Secondary Education (#P116B010948).


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© 2007 Association of American Medical Colleges