Hybrid Team- Based learning in cardiorespiratory physiotherapy education

Background: Today’s modern and future cardio-respiratory physiotherapist are, and will be, presented with ubiquitous and uncertain complex problems in professional life. Yet, to date, teaching approaches lacks robust scientific evidence of optimal learning to stimulate student’s active cognitive engagement of higher order skills beyond knowledge and skills transfer and are only focused on graduation. For past two decades, pedagogy recommends use of active learning strategies to enhance authentic student engagement, self-efficacy and satisfaction. In recent years, team-based learning (TBL) is emerging as a popular student-centred active


Hybrid Team-Based learning in cardiorespiratory physiotherapy education SD Perumal
Cardiff University, Wales, United Kingdom. 3

Introduction:
In 21st century, the cardio-respiratory curriculum has renewed demands on exit competencies for knowledge and skills of physiotherapy graduates to tackle unprecedented challenges of the growing healthcare industry (Troosters et al., 2019). Hence, it is crucial to reform the cardiorespiratory education process in higher education "that integrates generic skills and shapes students for professional responsibilities that transcend traditional boundaries of disciplinespecific roles." Over past two decades, series of influential reports and articles have highlighted traditional lectures fail to stimulate student engagement, accountability and self-efficacy (Bransford et al., 2000, Loftin and West, 2017, Weimer 2002. Recently, knowledge, evidence and learning for development report (2019) on the 'Framework for 21st Century Learning' summons education system to embeds the lens of '4Cs' -Critical thinking, Communication, Collaboration and Creativity in any teaching curriculum to prepare students for the demands in professional workforce. Ancient theories of learning by Jean Piaget (1926) and Lev Vygotsky (1978) have recommended "active learning" strategies to enhance student engagement, accountability and self-efficacy (Freeman et al., 2014). In fact, Bloom's Taxonomy is the core to the development of active learning strategies in the world of education (Bloom et al., 1994). In order to strengthen Bloom's higher order cognitive skills, such as application, analysis, synthesis and evaluation, an active learning strategy such as "visual learning, cooperative learning, debates, drama, discussions, role-playing and peer learning/teaching" should be embedded in the education curriculum delivery (Bonwell & Eison, 1991). This would stimulate students selfdirected learning and train attributes of scientific mindset such as curiosity, lifelong inquiry and learning (Madhuri et al., 2012).
In the last few years, emerging evidence support team-based learning (TBL), a special flipped instructional design focused on student centred collaborative learning that incorporates specific sequence of individual work, group work and immediate feedback to promote student's engagement and satisfaction (Sisk, 2011). A plethora of evidence affirms TBL enhances higher order skills, self-efficacy, teamwork, and academic performance (Branson et Livingston et al., 2014). This paper reports the design, implementation, and impact of a novel "Hybrid Team-Based Learning" (H-TBL) strategy on student engagement, accountability and self-efficacy. Furthermore, this study also aimed to explore impact on student's cognitive engagement in H-TBL.

Methods:
The presented retrospective data are from the academic year 2019 for a cohort of 136 students in Year 2 (level 5) of an undergraduate physiotherapy program at one of UK higher education institution. A novel Hybrid-Team-Based learning (H-TBL) strategy was implemented for one   6 The COPD 2 session was delivered for an hour in a large lecture theatre and comprised of Phases 2 and 3. The session began with an introduction to learning objectives, plus an outline of the in-classroom TBL session and rules of engagement emphasizing professionalism and teamwork. The students required to take closed book Team Readiness Assurance Test -tRAT for 10 questions designed in mixed format (multiple-choice questions with four choices and True/False) administered via Kahoot, a learning game platform. In each team comprised a minimum 3 to maximum 4 students and sharing of the devices was permitted. The lecturer provided a mini-lecture presentation following tRAT for 10-15 mins as highlights of major vital points or to clarify any points of confusion risen from the readiness assurance test with an opportunity of verbal appeal in the classroom. Verbal appeals on any "burning questions" were acknowledged, and the lecturer clarified any concepts that students did not understand relating to the test and the pre-class task (reading material). The verbal appeal qualifies as "burning questions" if either a) ambiguous question or b) discrepancy between a correct answer and reading content in COPD1 session (web-based). If it is an ambiguous question, the students 7 should identify the source of ambiguity that would improve clarity and resolve the issue. The timeline for verbal appeals allocated was 2 mins following each question in MCQ's.

Phase 3 comprised application exercise that involves peer discussion (20 mins) and
presentation to whole class (3 mins per team) on a given theme related to a journal article different from COPD 1 session. The framework for application exercise adheres to the "4S" principle: A diligent task design around a "Significant" problem, the COPD with a focus on the "Same" question on disease management with "Specific" choice relevant to journal article and students were reporting "Simultaneously" their answers and views to the whole classroom for immediate feedback (Michaelson and Sweet, 2008). For phase 3 activity, the students were reshuffled in teams (5-7 students) and peers elected their team representatives (one or two students). Representatives were instructed to facilitate team discussion and scribe the points in a sticky note. At the end of discussion, each team presented a reflective account to varying degrees of depth and rationale of their team's decision on given theme. The lecturer facilitated the intra team debate. After each reporting, the lecturer clarified and added critical supporting points. A mini test was exercised through "Mentimeter" to confirm and promote understanding of the session's context and contents. Before the close of the session, students' feedback on the COPD 2 session was captured through "Mentimeter".
Phase 4 involves out of class activity post completion of COPD 2 session. This phase was introduced to infer students' reflection on COPD disease and management. Students were challenged with a formative creative assignment on a common theme, "Exacerbation," to promote critical reflection on their application exercise (phase 3) on recommendations for evidence-based management of COPD. Students autonomy was developed with a choice of either a blog of the maximum word limit of fifty or a PowerPoint with a maximum of five slides or one-page infographics. Students were set on a target of 10 days to complete and submit the task on the university learning management system (Turnitin). Lecturer instructed students 8 that the creative assignment is not summative assignment or neither add credits towards the module. The students work was assessed by lecturer using "Rubrics on student's reflection"    The overall outcome of H-TBL was measured based on three main domains, as discussed below:

Figure 4-Student Engagement
The students' cognitive engagement measured based on their response in tRAT (Phase 2) and performance in formative creative assignment (Phase 4). The percentage of student's right responses to MCQs in tRAT of phase 2 is shown in Table 1. And it was captured via Kahoot, an interactive educational gaming platform. The creative assignment was assessed using on a rubric for student's reflection as a benchmark tool (Figure 3). Based on the rubric, 5/67 (7%) students were graded excellent, 56/67 (83%) students graded good and 6/67 (9%) students graded near expectation.   ). An impressive performance data was observed both in tRAT and formative creative task activities demonstrates their self-efficacy in knowledge acquisition (Loftin and West, 2017).
Notably, the completion of a creative assignment challenge in phase 4 revealed students' talents of creativity, proclivity, innovation, and ownership for knowledge acquisition. Thus, it gives confidence that H-TBL has potential to promotes a culture of self-regulated learners and community of inquiry as illustrated by Garrison et al. (2000).
Furthermore, the author also believes the introduction of incentive system in phase 4 for the creative assignment had opened the channels of enthusiasm and a collegiate competition among students. Overwhelming response to creative work submission supports phase 4 of H-TBL had sparked student's heightened cognitive engagement, self-efficacy in the subject content at hand. Given the evidence, it can be believed H-TBL design and delivery had the potential to produce 21st century self-sufficient cardio-respiratory physiotherapists in the growing healthcare industry. Upon reflection on the student's engagement, performance and feedback data, there is potential for transferability of H-TBL across other cardio-respiratory, musculoskeletal, and neurology modules in our physiotherapy program. These data are rich sources of information that could inform a consistent quality improvement in curriculum development and program evaluation. However, there were both human and logistical challenges encountered pre and post H-TBL design, development and delivery in our institution. 15

Challenges:
The primary challenge was in converting a face to face lecturer into a web-based interactive lecture was highly challenging. This demands lecturer's workload, skills and patience to design, develop and deliver the subject content in sequence with use of appropriate tools to promote authentic student's active learning experience (Khan et al., 2017). A pinnacle of challenge at implementation stage which experienced a widespread resistance among other lectures in physiotherapy teaching teams to acknowledge H-TBL. This behaviour of resistance from our lecturers to new teaching strategies correlates with pre-existing evidence that though universities are willing to adopt effective teaching-learning methods, often teaching practices in healthcare courses lacks training in practice performance or task design due to resistance from some students or lecturers or cultural perceptions of institution (Topbas,  Another perceived barrier was student's attitudes and behaviours for classroom engagement. From a teaching perspective, it was observed some students reported poorly prepared for COPD 2 session that reflects a variant in usage patterns of online content for individual preclass work. The author attributes this to barriers of logistics support (scheduling) which could be one of the factors reflecting implicit bias on students' engagement. In addition, during phase 3 (application exercise) it was notable that some students' unwilling to challenge colleagues, lack confidence to voice their ideas or opinions to the class and educator, and anxious during presentation though it was not part of the module summative assessment. A plausible reason might be as the task design was matched to real-life scenarios, it might have challenged some student's coping skills to demands on accountability, working in teams, being creative, and 2019) though the majority of our students were satisfied and embraced the novelty learning opportunities in H-TBL design, whilst some students expressed dissatisfaction and preferred a conventional lecture. In our renewed higher education system, student satisfaction is gaining as a prominent metric to quantify teaching quality (Langan and Harris, 2019). This might elicit an inquiry in our evidenced results on student engagement and performance. However, it's been documented, increased student's satisfaction does not have any direct relationship with their engagement and performance. In accordance with experiential learning theories, some students entwin their response of transition from novice to expert learning experience as "discomfort" and "vulnerable to emotions" that challenges their resilience and grit to become an expert in a given subject (Experiential Learning, 2020) Last, but not the least, team formation was a great challenge and teams were assigned randomly during the COPD 2 session. The author believes this had given the team a potential mix for diverse intelligence quotient, personality and learning behaviours, promoting depth of accountability to self and peer's professionalism, an expected standard of conduct required by accreditation bodies of physiotherapy practice.

Limitations
The author perceives that this study has several limitations. First, this study design is retrospective and lacks a control group. Second, this study results cannot be generalized as it only reports the effects of TBL for one lecture in the cardio-respiratory module of a 3-year undergraduate physiotherapy program. Third, this study only reports on overall student engagement and does not explore students' cognitive engagement in different TBL phases or differences between elite and low performers. Fourth, the rate of student's class attendance cannot be commented as there was no previous data for the same session. Fifth, there was no validated instrument (e.g. questionnaire or focus group interviews) to capture students' perceptions to culminate qualitative data. Sixth, this study does not explore long term impacts on students learning and academic performance. Seventh, the lecturer is blinded to data on students learning disabilities that could have had a ceiling effect in the depth of student's engagement in peer discussion, presentation and completion of formative creative assignment.

Conclusion:
This study is first of its kind to introduce H-TBL in our cardio-respiratory module of undergraduate physiotherapy programme. Despite the challenges and limitations mentioned above, this study supports that H-TBL can foster self-regulated active learners, with 21 st century '4Cs' Skills (Critical thinking, Communication, Collaboration and Creativity) for scientific mindsets. Adopting TBL, with appropriate instructional content, design and incentive strategies, can increase student cognitive engagement both inside and outside the classroom.
This H-TBL design offers a framework for lecturers to construct active learning ambience mapped to sound pedagogical principles to close theory -practice gap. However, prospective randomized studies are warranted to confirm the validity and specificity of H-TBL compared to conventional lectures on academic performance, self-efficacy, content mastery, attitudes of students and educators. 18

Future directions and recommendations:
Beyond application in one lecture on the cardio-respiratory module, there are several implications for employing H-TBL into learning. First, the importance of widening student's engagement cannot be underestimated. For this, it would be valuable to consider revising the module planning and potentially introducing the learning strategies for every lecture in the student handbook that could relinquish the control and management of student ownership to active learning. Second, to control time commitments, creating a living physiotherapy curriculum with learning contracts could appeal to diverse individual learning styles and students' academic bents. Third, supporting and developing a culture of openness to H-TBL approach between students and educators would unveil the ambiguity of its efficacy in the light of student benefits. Fourth, a monthly update on subject-specific active pedagogical practices would enhance co-operation and confidence among educators in active teaching-learning design, implementation methods, and benchmarking practices at the local, national and international arena. Fifth, lecturers' initiatives to co-create TBL rubrics for both formative and summative assessment with students would increase student's passion for active engagement in relevant subject and courses.

Acknowledgement
The author would like to acknowledge the support from both Ms. Rebekha Potton, learning technologist, School of Healthcare Sciences, Cardiff University, United Kingdom and Mr.
Owen Crawford, learning technology officer, Centre for Education support and innovation, Cardiff University, United Kingdom for assistance on formatting and administrative support for developing the web-based content for COPD Session 1 of H-TBL (Phase 1). The author sincerely like to record her gratitude to Dr. Mark Davies, Senior Lecturer in Advance Practice, University of South Wales, United Kingdom and Dr. Michale Rowe, Associate Professor and the Departmental Chairperson of Physiotherapy at UWC for critical peer review to add more clarity to this paper. Prior to critical peer review, this article has been submitted to pre-print.org on 18th August 2020 and accepted on 20th August 2020 for pre-print versionhttps://www.preprints.org/manuscript/202008.0463/v. The author confirms this is a renewed version.

Funding
No funding received and article produced in author's personal time.

Conflict of interest
The author reports no conflict of interest. The author is solely responsible for the content and writing of the article.
Ethical Approval: N/A-Anonymised retrospective study reporting on teaching practices.