Course: PHL 240 Health Care Ethics
Department: Philosophy and Comparative Religions
Institution: Cleveland State University
Instructor: Dr. Tatiana Gracyk
Number & Level of Students Enrolled: 40 undergraduate students per section, 2 sections
Digital Tools/Technologies Used: Blackboard, Student’s choice for team communications
Author Bio: Dr. Gracyk is an assistant college lecturer at Cleveland State University. Her primary research interest is in biomedical ethics, focusing on evaluating frameworks for decision-making in healthcare. Her teaching is similarly focused on biomedical ethics, frequently utilizing the instructional design principles of Team-Based Learning to prepare her students for working in the healthcare field. She also serves as a member of the University Hospitals Cleveland Medical Center ethics committee
Team-Based Learning: From the Classroom to Online
In my Health Care Ethics course, students are empowered to deliberate together in order to make recommendations in difficult clinical cases. In the classroom setting, this has meant students spend much of their time actively engaged with their team members deploying a provided framework to analyze and evaluate provided cases. This Team-Based Learning (TBL) approach, a sub-species of flipped learning, has increased student engagement and enhanced the development of the reasoning and communication skills essential to healthcare professionals. In transitioning to remote delivery mid-semester, I aimed to adhere to the principles of TBL while restructuring the class to better fit an online environment. I found both successes and failures and will, in this essay, focus predominantly on two main elements of TBL: The Readiness Assurance Process and the team Application Activities.
1. What is Team-Based Learning?
TBL is a flipped learning instructional strategy that focuses on team-based in-class activities, such as analyzing an argument or evaluating a case in order to make a recommendation. These activities are intentionally designed to be too difficult for an individual to resolve on her/his own, and involve teams deliberating over which provided course of action to take and why, rather than over the possible courses of action. TBL also divides the course into distinct learning modules, with each module focusing on understanding and using specific concepts or theories. Each learning module begins with the Readiness Assurance Process (RAP) to ensure a basic grasp of the relevant terms as well as accountability to the team. The RAP is imperative to a successful “flipped classroom” because it ensures that students are familiar with the relevant material at the outset of the module, allowing for students to practice working with this material during the team Application Activities that follow. Most of the module consists of these team activities where students work together on guided activities. The following sections will explain how I implement the RAP and Application Activities in the classroom before examining the transition to an online format.
2. TBL in the Classroom
It is standard practice in TBL that each module begins with the Readiness Assurance Process (RAP), a short quiz based on the assigned readings and aimed at ensuring individual accountability to the team. The RAP also helps to identify and clarify confusions that arise in connection with the assigned readings, preparing students for the team Application Activities that make up the remainder of the module. As opposed to assigning weekly readings, TBL has students complete the entirety of a module’s readings prior to the start of that module. The first day of each module then begins with a reading quiz which is taken twice: Students are first given ten minutes to complete the individual readiness assessment test (iRAT), and then immediately re-take the same quiz as a team (tRAT). Teams are given fifteen minutes to complete the tRAT, and team members must agree on which answer is likely correct. Teams receive immediate feedback using a special scratch-off scoring card. If the team does not answer correctly, they must continue discussing the question until they get it right. This process encourages students to work together to more fully understand the course concepts and allows students to re-explain the material in their own words.
The rest of the module is then devoted to Application Activities, team problem-solving exercises that help students to develop their critical thinking skills by applying course concepts. In my Health Care Ethics course, the team activities utilize realistic bioethical case studies along with guided worksheets to teach students how to approach and analyze the types of complex ethical cases that arise in healthcare. Students generally examine four case studies in each module, one case per class meeting, and are provided 30-40 minutes of class time to discuss each case and complete the worksheet. In addition to guiding team discussions, the worksheet functions as a record of the team discussion and grading these worksheets provides an opportunity for constructive feedback. The final question on each worksheet requires that the team reaches a consensus on a recommendation for a course of action regarding the case, and this recommendation is justified by appeal to the moral framework. The teams then simultaneously share their recommendations, moving the class period from the team activity portion to the class discussion portion of the day. During the class discussion, each team is called on to explain and defend their reasoning publicly. This class discussion is important in that it provides another opportunity to experience reasonable disagreement, see additional ways of using course concepts, and offers a chance for the instructor to provide corrective feedback.
 The case studies used for the team Application Activities are an exception to this. Instead of being read prior to the start of the module, the cases are assigned throughout the module as they relate to each day’s activity.
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3. Transitioning TBL to Online
In transitioning the course to an online format, I had my students continue working in their fixed teams, they still began each module with the RAP, and I assigned two case analyses each week consistent with the workload before the transition. However, I chose to eliminate the tRAT component of the RAP because the most straightforward way to administer the reading quiz was to use the “test” feature in Blackboard, and this unfortunately does not include a team-test option. To compensate for the loss of the tRAT, I provided brief explanations displayed alongside the correct/incorrect answers. However, students frequently expressed confusion regarding how to re-enter the quiz in order to see this written feedback, and I suspect that the majority of the students did not look back at the quiz answers or the feedback I provided. I found that without the tRAT, the RAP largely failed to clarify complex concepts, instead functioning to encourage individual accountability and assess the students’ reading comprehension.
For the team activities, each team was instructed to discuss the case and submit a single set of answers for each worksheet. Teams could choose their preferred methods of communication, and I also created team-specific discussion boards to ensure teams had a clear space in which to discuss the cases. However, no teams used the discussion boards, instead utilizing a range of methods including video chats, email messages, texting, and in one case relying on the SnapChat app. Instead of having teams then share their recommendations as they did in the full class discussion, I chose to write up a variety of answers for each of the worksheet questions, explaining the different answers that could or could not be justified for each question. The goal was to demonstrate reasonable disagreement and offer corrective feedback in addition to the individualized comments provided to each team.
4. Lessons Learned
There were some notable benefits to having teams work in an online format. I quickly discovered that many of the teams submitted more in-depth case analyses than they had in the classroom. When completing the team activities in class, the teams spent much of the activity time verbally discussing the case only to provide a short (one or two sentence) hand-written justification of the team consensus for each question. When the course transitioned to an online format, team discussions were no longer limited by the allotted class time and answers could be typed in much greater detail. This allowed students to explain their justifications in much greater depth, to draw connections between the cases and concepts, and to express more comprehensive ideas. Continuing to work in their fixed teams, even asynchronously, also helped many students to feel connected and involved post-transition.
However, there were several drawbacks to working online. As expected, some students failed to contribute to the team discussions in the online setting, and poor choices in communication tools, such as a reliance on texting, may have contributed to this. When no longer required to meet face-to-face, it became easier for students to decrease their involvement in contributing to the assignments. Some teams also reported that they distributed the worksheet questions among the team members instead of discussing each question as a team. While this presumably helped to ensure that each team member contributed to the assignment, these students may have missed out on seeing how the questions related to or built on one another. Because the worksheets are designed to systematically guide students through differing considerations, with most questions being open to debate, distributing the questions among the individuals meant losing out on the deliberative component of the team activity as well as the systematic approach to reaching a resolution.
Providing corrective feedback also became more challenging in the online setting, especially for the team discussions. In the classroom, I would regularly sit down with each team to assist in their discussions and coach them on proper use of the course concepts. Unfortunately, I could not engage in the same way in an online setting. Instead, I allowed teams to submit drafts of their completed assignments prior to the deadline, at which time I would offer corrective feedback without penalty. On average, three out of four teams took this opportunity to submit drafts. However, in at least some cases the individual submitting the draft would make corrections or revisions without consulting with the rest of the team. While this resulted in improved assignments, failing to revise the work as a team meant that the other team members did not benefit from re-thinking the case based on the provided feedback.
5. Potential Improvements
A simple change to resolve several of these issues would be to provide a limited set of communication options for teams to choose from. For example, by requiring the use of discussion boards I could both verify each team member’s involvement and offer corrective feedback mid-way through their discussions. This would eliminate the need to review drafts of their assignments, cutting the instructor workload in half, and would ensure that each team member had access to the instructor feedback. By not requiring a specific number of discussion posts or replies, teams could still be autonomous in and accountable for the discussions, helping students to develop as self-regulated learners. Similarly, instead of the instructor writing up answers to the questions, an alternative method of re-creating the class discussion component could be to require teams to provide both a recommendation and an alternative recommendation. This would require the teams to consider each case from a variety of viewpoints, demonstrating an understanding of reasonable disagreement and differing perspectives. Requiring teams to post their recommendations publicly, such as on a full class discussion board, could also be a productive way of highlighting reasonable disagreement and the value of thinking through different perspectives.
Lastly, I think it would be useful to record short, 5-7-minute videos introducing each team activity. This would allow the instructor to explain any needed content and set up the case as would be done in the classroom. By recording these lectures in advance, the course and discussions could be conducted asynchronously. An optional, live video meeting mid-week would be additionally helpful for addressing any questions or clarifications. In all, I think TBL is well-suited for the online environment in that it encourages student participation and allows students to practice applying course concepts while receiving constructive feedback. However, successfully transitioning in-class TBL principles to the online setting requires first considering the learning outcomes of each activity and then some thoughtful adjustments in order to ensure that these learning outcomes are still being satisfied through the online assignments.