Content area
Aims
To evaluate the short-term effects of team-based learning (TBL) on self-directed learning (SDL), cooperative learning, and critical thinking among nursing students enrolled in a medical-surgical nursing course.
Background
Studies examining the short-term retention effects of TBL on nursing students’ core competencies are limited.
Design
A quasi-experimental study.
Methods
Data were collected from nursing students aged 17–18 years who were enrolled in a medical-surgical nursing course. Students recruited in the first year (n = 101) were assigned to a control group and received traditional lecture-based instruction on cardiovascular care, whereas those recruited in the second year (n = 98) were assigned to a TBL group and received instruction on the same topics. Both interventions were delivered 2 h per week for 5 weeks. The students’ SDL, cooperative learning, and critical thinking were assessed at baseline, postintervention, and 5 weeks after the intervention.
Results
Compared with the control group, the TBL group showed greater improvements in SDL, cooperative learning, and critical thinking at both postintervention and the 5-week follow-up. Within the TBL group, SDL and critical thinking were maintained during the follow-up, whereas cooperative learning declined significantly but remained higher than in the control group.
Conclusions
Implementation of TBL enhances nursing students’ core competencies more effectively than traditional lecture-based teaching. Short-term benefits in SDL and critical thinking appear sustainable, whereas cooperative learning may need support to ensure lasting improvement. Further research is needed to assess the long-term retention of core competencies acquired through TBL, with particular attention to cooperative learning.
1 Introduction
Traditional lecture-based teaching is insufficient for fostering student engagement and meeting the evolving needs of learners ( Seo and Park, 2025). Therefore, team-based learning (TBL), an effective, student-centered instructional strategy, has increasingly been adopted in nursing education ( Şen Olgay and Çağan Kişin, 2025). The design of TBL encourages active participation, collaborative learning, and the development of a sense of personal accountability for one’s learning ( Qu et al., 2024). Several studies have demonstrated that the TBL approach can effectively enhance nursing students’ academic knowledge and clinical performance ( Qu et al., 2024; Wang et al., 2024; Zhang et al., 2024a). In general, undergraduate nursing curricula are designed with a focus on not only promoting academic success but also cultivating essential professional competencies ( Seo and Park, 2025). Such a focus is particularly relevant in medical-surgical nursing courses, where course content has a strong influence on students’ clinical performance ( Ogunlowo and Ajibade, 2024). In such courses, students are expected to develop key competencies such as self-directed learning (SDL) ( Hu et al., 2024), cooperative learning ability ( Cheng et al., 2024), and critical thinking ( George, 2024), all of which are essential to sound clinical decision-making and high-quality patient care. Therefore, investigating the effectiveness of TBL in enhancing SDL, cooperative learning, and critical thinking in medical-surgical nursing courses has potential to provide valuable insights that can aid in advancing nursing education.
2 Background
TBL, first proposed by Larry Michaelsen in the 1970s, is widely regarded as one of the most effective instructional strategies for promoting active learning among students ( Murata et al., 2023; Şen Olgay and Çağan Kişin, 2025). The design of TBL courses involves small-group, student-centered learning that follows a structured sequence involving individual preparation, team collaboration, and immediate feedback. This sequence supports the development of student motivation to engage in active learning ( Seo and Park, 2025). In TBL, the focus of instruction shifts from teacher-led lectures to student-driven discussions and problem-solving activities, and therefore, TBL promotes deeper comprehension of a target subject and helps create a more dynamic and interactive learning environment ( Şen Olgay and Çağan Kişin, 2025).
A typical TBL session is implemented using a three-step instructional cycle comprising pre-class preparation, a readiness assurance process, and application activities ( Murata et al., 2023). During the pre-class preparation phase, instructors provide instructional materials that enable students to preview and gain a preliminary understanding of upcoming content. In the readiness assurance process, students complete an individual readiness assurance test (iRAT), a team readiness assurance test (tRAT), and an instructor-led clarification review. During this process, students are typically divided into teams of 5–7 people to facilitate collaborative discussions ( Yeung et al., 2023). In the application phase, students work in teams to solve problems based on realistic scenarios, with this followed by discussions involving the entire class ( Chen and Tsai, 2024; Vannini et al., 2022). Prior systematic reviews and meta-analyses have indicated that TBL sessions typically last between 100 min and 2 h and are conducted weekly and that intervention periods generally range from 3 to 8 weeks ( Seo and Park, 2025; Yeung et al., 2023). Several studies have demonstrated that TBL enhances students’ SDL by improving their ability to identify relevant learning resources and effectively manage their own learning ( Chen and Tsai, 2024; Hu et al., 2024).
SDL is a process where learners take initiative to identify their learning needs, set goals, select strategies and resources, and determine appropriate assessment methods and consider themselves responsible for doing so. It also involves students developing sustained motivation to integrate learning into their daily lives ( Knowles, 1975). SDL is a vital skill for nursing students, contributing substantially to their academic achievement and learning satisfaction ( Chen and Tsai, 2024). Students who develop the ability to engage in SDL are more likely to participate in lifelong learning, which is a core competency in professional nursing practice ( Premkumar et al., 2018).
A key feature of TBL is its emphasis on team-based discussions, where students collaborate to brainstorm solutions to problem and learn from one another, which enhances their cooperative learning ability ( Zhang et al., 2024b). Cooperation is an essential competency for nursing students in both academic and clinical contexts because it is fundamental to the delivery of high-quality patient care ( Xu et al., 2025). In the TBL process, students are encouraged to participate in small-group discussions, with a preference for heterogeneous group composition ( Wang et al., 2021). Interacting with peers from diverse backgrounds enables students to critically reflect on their own learning styles and adopt effective strategies modeled by others ( García-Expósito et al., 2025). This peer interaction during TBL also contributes to the development of critical thinking skills ( Yeung et al., 2023).
Critical thinking is one of the most crucial competencies that nursing students must develop during their academic training; it plays a critical role in clinical decision-making, problem-solving, and the delivery of safe and effective patient care ( Nekouei et al., 2024). Critical thinking involves an intentional and reflective process of making informed judgments through interpretation, analysis, evaluation, and inference, with all supported by careful consideration of evidence, concepts, methods, and context ( Sarkoohi et al., 2024). Numerous studies have reported that critical thinking can be strengthened through well-structured course design interventions ( Yeung et al., 2023; Zeb et al., 2022).
Although previous studies have suggested that TBL may enhance students’ SDL, collaborative learning, and critical thinking, few have examined whether these effects can be sustained over time ( Bleske et al., 2018; Roossien et al., 2025). Existing studies that have investigated the retention effects of TBL have reported inconsistent findings ( Alimoglu et al., 2017; Bleske et al., 2018; Roossien et al., 2025). One study reported that students maintained higher levels of knowledge retention than the control group 1 year after TBL implementation ( Alimoglu et al., 2017). However, most existing evidence suggests that the effects of TBL are limited over time ( Bleske et al., 2018; Emke et al., 2016). Bleske et al. (2018) found that, 6 months after TBL, students’ knowledge retention had markedly declined, showing no significant difference compared with the lecture-based learning group. Similarly, Emke et al. (2016) assessed students before their clerkship, approximately 8–40 weeks after TBL, and reported no significant difference in knowledge retention. All of these studies have primarily focused on the retention of professional knowledge rather than on the development of students’ core competencies. To address this gap, it is essential to examine whether TBL can foster sustainable improvements in these competencies.
In nursing curricula, such competencies are expected to be cultivated systematically through foundational courses across undergraduate programs ( Gao et al., 2024; George, 2024). Medical-surgical nursing is a fundamental course that is required in undergraduate nursing education ( Ogunlowo and Ajibade, 2024). In Taiwan, students must complete a medical-surgical nursing lecture course before they begin their practicum. However, few studies have examined how TBL-based instruction in such foundational courses influences the development and short-term retention of these competencies ( Ali-Abadi et al., 2020; Xu et al., 2024). Therefore, the present study aimed to evaluate both the immediate and short-term effects of a 5-week TBL intervention on nursing students’ core competencies.
3 Aims
The purpose of this study was to explore the short-term effectiveness of the TBL approach in enhancing SDL, cooperative learning, and critical thinking among nursing students enrolled in a medical-surgical nursing course. We hypothesized that nursing students in the TBL group would demonstrate higher levels of SDL, cooperative learning, and critical thinking than those in the traditional lecture-based instruction group, both immediately after the intervention and at the 5-week follow-up.
4 Methods
4.1 Design and sample
This study employed a quasi-experimental design with convenience sampling. Participants were recruited from a 5-year nursing junior college in southern Taiwan. The program spans 5 years, and graduates obtain a qualification equivalent to an associate degree in nursing. Eligible participants were third-year students who were enrolled in the medical-surgical nursing course for the first time. Students who had previously taken or failed the course, or who declined to participate, were excluded.
4.2 Sample size
G*Power, version 3.1.9.7, was used to estimate the required sample size for this study. On the basis of previous TBL intervention studies with similar designs ( Daou et al., 2022; Ulfa et al., 2021), a two-tailed t-test was set with a significance level of 0.05, an effect size of 0.55, and a power of 0.80. The calculation yielded a minimum required sample size of 106. To account for an anticipated 10 % attrition rate during the intervention period ( Ulfa et al., 2021), a total of 118 participants were planned to be recruited, with 59 students per group .
4.3 Data collection and procedures
Data collection and the intervention were conducted over a two-year period from September 2019 to January 2021. To avoid potential cross-class contamination and to address ethical concerns regarding unequal learning opportunities within the same cohort, students in the control group were recruited in the first year, whereas those in the experimental group were recruited in the second year. The research team first informed the students of the study procedures and purpose, and clarified that participation was voluntary and would not affect their academic rights or grades. For underage students, informed consent forms were sent to their parents or guardians. After providing consent for participation, the students completed questionnaires that required approximately 10 min. To minimize potential confounding and maintain consistency within the same learning environment, the follow-up assessment was scheduled 5 weeks after the intervention, within the same academic semester. This time frame was also informed by previous research indicating that retention effects may begin to decline approximately 8 weeks after TBL ( Emke et al., 2016). Data were collected at three time points: baseline (T 0), postintervention (T 1), and 5-week follow-up (T 2). To minimize potential power imbalances, a research assistant handled all raw responses, and the first author, as course instructor, had no direct access to the completed questionnaires.
4.4 Intervention
The experimental group received 2 h of TBL-based instruction per week for 5 weeks as part of their medical-surgical nursing course. By contrast, the control group underwent the same 2-hour weekly instruction over 5 weeks, through traditional lecture-based learning, without any additional self-learning activities. During the intervention periods, the two groups covered identical course content related to cardiovascular nursing, including regarding providing care to patients with arrhythmia, angina pectoris, myocardial infarction, heart failure, and hypertension. Because the groups participated in the study in different academic years, they did not influence each other’s results. A flowchart illustrating the intervention procedures for the experimental and control groups is provided in
4.4.1 TBL pre-class preparation
Participants in the experimental group were organized into teams of 5–6 members on the basis of their academic rankings, which ensured a balanced mix of high- and low-performing students in each team prior to class. The first author, an instructor with over 20 years of experience in teaching medical-surgical nursing, prepared and distributed TBL instructional materials 1 week prior to the lesson where the material was taught to enable self-directed preparation for the class. These materials included PowerPoint slides and teaching videos recorded by the first author.
4.4.2 TBL readiness assurance process and application activities
At the beginning of each class for the experimental group, the first author administered the iRAT by using Zuvio. The iRAT comprised 10 multiple-choice questions and required approximately 5 min to complete. Scores were recorded individually. After completing the iRAT, the students worked collaboratively on the tRAT for 10–15 min ( Vannini et al., 2022), considering the same set of questions that they had independently responded to at the start of class. Team scores were recorded by using the immediate feedback assessment technique (IF-AT). On completion of the readiness assurance process, the first author conducted a 15- to 20-minute review, either delivering a mini-lecture or using a concept map to help students clarify and reflect on key learning concepts.
For the TBL application activities, each team received a simulated case scenario related to heart disease. The team members spent approximately 20–25 min discussing how nursing should be administered to provide patient care in the given scenario, with this followed by 25–30 min of the groups sharing their insights with the rest of the class ( Vannini et al., 2022). The first author then concluded the session with a 15- to 20-min summary that highlighted the main points of the lesson, key takeaways from the case discussion, clarification of misconceptions related to caring for patients with heart disease, alignment with course objectives, and encouragement for students to reflect on their learning.
4.5 Instruments
This study adopted three instruments to evaluate participants’ SDL, cooperative learning, and critical thinking.
4.5.1 Self-Directed Learning Instrument
This study used the Self-Directed Learning Instrument (SDLI) developed by Cheng et al. (2010) to evaluate the participants’ SDL ability. The SDLI comprises 20 items across 4 domains: learning motivation (6 items), planning and implementing (6 items), self-monitoring (4 items), and interpersonal communication (4 items). It uses a 5-point Likert scale, with item scores ranging from 1 (strongly disagree) to 5 (strongly agree), where higher scores indicate a greater level of SDL ability. The instrument has undergone rigorous reliability and validity testing, including two rounds of Delphi review and confirmatory factor analysis. The original study reported a Cronbach’s α of .92 ( Cheng et al., 2010). In this study, the Cronbach’s α was .92. The SDLI is widely used to evaluate SDL outcomes among nursing students ( Gao et al., 2023; Huang and Fang, 2023).
4.5.2 Cooperative Learning Experience Questionnaire
The Cooperative Learning Experience Questionnaire developed by Chang et al. (2014) was used to evaluate the participants’ cooperative learning experiences. This instrument has previously been applied in Taiwan to assess cooperative learning among university students ( Chang, 2020; Chen, 2022). It comprises 19 items across two domains: learning motivation and attitude (8 items) and peer interaction and cooperation (11 items). Responses are measured on a 5-point Likert scale, with responses ranging from 1 (completely disagree) to 5 (completely agree), with higher scores indicating more positive cooperative learning experiences. The original study reported a Cronbach’s α of .91 ( Chang et al., 2014) and the Cronbach’s α in the present study was .91.
4.5.3 Critical Thinking Intention Scale
The Critical Thinking Intention Scale was used in this study to evaluate the participants’ critical thinking intentions and attitudes. Originally developed by Yang (2006) and later revised by Tsai (2009) to improve its applicability. The instrument comprises 16 items grouped under three domains: open-mindedness (7 items), systematicity (6 items), and sensitivity (3 items). The scale uses a 5-point Likert scoring with each item ranging from 0 (never) to 4 (always). Higher scores indicate stronger critical thinking intentions or more favorable attitudes. The scale has undergone comprehensive validation, including exploratory and confirmatory factor analyses, assessments of convergent and discriminant validity, and Rasch analysis using a sample of 1291 students. The Infit and Outfit mean square values for the items ranged from 0.78 to 1.22, indicating a good model fit ( Tsai, 2009). The original version of the scale had a Cronbach’s α of .86 and a test–retest reliability of.62 over 2 weeks ( Tsai, 2009). In the present study, the Cronbach’s α for the overall scale was .94.
4.6 Ethical considerations
This study was approved by the human research ethics committee of a university in Taiwan (approval numbers: NCKU HREC-E-108-394-2 and NCKU HREC-E-109-402-2). To ensure fairness and protect the rights of both groups, all participants received instruction on the same learning topics. The students were informed that their decision to participate or withdraw from the study would not affect their academic rights or grades. To allow participants to feel comfortable in deciding whether to take part, consent forms and questionnaires were collected separately in sealed envelopes. Although the surveys were not fully anonymous because student ID numbers were used for follow-up paired analysis, all identifiers were removed before statistical analysis to safeguard confidentiality.
4.7 Data analysis
All data analyses were conducted using SPSS (IBM SPSS Statistics for Windows, version 24.0, IBM Corp., Armonk, NY, USA). An independent t-test was used to compare differences in SDL, cooperative learning, and critical thinking at baseline between the two groups. Generalized estimating equations (GEEs) with a first-order autoregressive structure were used to examine changes in outcome scores at baseline, postintervention, and 5 weeks after the intervention to evaluate the effectiveness of the TBL strategy. A paired t-test was used to examine the difference in outcome scores between the post-intervention and 5-week follow-up time points in the TBL group. A p-value of less than .05 was considered statistically significant.
5 Results
A total of 199 nursing students were enrolled (control group:
n = 101; TBL group:
n = 98), drawn from two consecutive years. No missing data were identified across all time points measured in either group. Participants in both groups were aged between 17 and 18 years. Most participants in both groups were female students, with 10 male students in the control group and 7 in the TBL group (χ² = 0.484,
p = .614).
The effects of the intervention on SDL, cooperative learning, and critical thinking, as assessed using GEE analysis, are presented in
6 Discussion
This study recruited a large sample to examine the effectiveness of TBL in enhancing SDL, cooperative learning, and critical thinking among nursing students enrolled in a medical-surgical nursing course and to examine the sustainability of these improvements over time. The findings revealed that students who received 2 h of TBL per week for five consecutive weeks demonstrated significant improvements in all three core competencies. Although cooperative learning in the TBL group declined significantly from T 1 to T 2, the TBL group still scored significantly higher than the control group at T 2 on SDL, cooperative learning, and critical thinking.
Our study results are consistent with those of previous studies indicating that TBL is an effective instructional strategy for improving nursing students’ SDL ( Gao et al., 2024; Wang et al., 2024), cooperative learning ( Vlachopoulos et al., 2021), and critical thinking abilities ( Wang et al., 2024; Yeung et al., 2023). In addition, the students in the TBL group were more engaged in the course activities, which contributed to a dynamic and interactive learning environment being established. Our study is similar to previous researches that employed simulated scenario cases through a TBL strategy and used a comparable intervention dosage ( Kim et al., 2016; Lee and Park, 2021). However, unlike prior studies that typically limited their sample size to fewer than 100 participants, our relatively larger sample size in the present study enhances the reliability of the findings ( Seo and Park, 2025; Yeung et al., 2023).
The most notable finding of the current study was the sustained improvement in SDL and critical thinking among students in the TBL group over a 5-week period. Although cooperative learning showed a decline from postintervention to follow-up, it remained significantly higher than that of the control group. While the maintenance of improvement in core competencies at follow-up may not be solely attributable to the TBL intervention, the study conducted a follow-up within the same academic semester. Therefore, students in both time points of postintervention (T 1) and 5-week follow-up (T 2) were exposed to comparable learning environments and educational contexts. To the best of our knowledge, the present study is the first to examine the short-term effects of TBL on nursing students’ core competencies. Further research is needed to validate our findings and to clarify the long-term effects of TBL on nursing students’ core competencies. In addition, this study observed limited improvements in cooperative learning in the TBL group at follow-up. Therefore, we recommend combining TBL with other innovative teaching strategies to enhance its overall effectiveness. This suggestion is consistent with findings from a meta-analysis on this topic involving a large sample of nursing students ( Gao et al., 2024).
This study has several limitations that should be acknowledged. First, although the sample size was large enough for statistical analysis, the quasi-experimental design and convenience sampling from a single institution may limit the generalizability of the findings. Second, the study was limited to core competencies, including SDL, cooperative learning, and critical thinking, and it did not assess academic performance or other learning-related variables. Third, using different academic years for the experimental and control groups reduced cross-class contamination and ethical concerns, but may have introduced cohort-related bias. In addition, because students could not be blinded to group assignment, their awareness of being in either the intervention or control group may have introduced social desirability response bias. Finally, this study included a 5-week short-term follow-up conducted within the same academic semester, allowing us to demonstrate the short-term sustainability of TBL’s impact. Future longitudinal research is recommended to examine the long-term effects of TBL on students' development.
7 Conclusion
The present study demonstrated that a 5-week TBL strategy, delivered for 2 h per week, significantly improved nursing students’ SDL, cooperative learning, and critical thinking in a medical–surgical nursing course. These gains were retained over the subsequent 5 weeks. Although cooperative learning in the TBL group declined slightly at follow-up compared with immediately after the intervention, it remained higher than that of the control group. Further research is warranted to explore the long-term effects of TBL on the retention of core competencies among nursing students.
CRediT authorship contribution statement
Yu-Hsuan Chang: Writing – review & editing, Writing – original draft, Validation, Supervision, Software, Methodology, Formal analysis, Data curation, Conceptualization. Pao-Chen Lin: Visualization, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
This work was supported by the
Table 1
| Parameters | TBL group
(n = 98) |
Control group
(n = 101) |
t | p | ||
| Mean (SD) | Mean (SD) | |||||
| SDL | 70.94 | (9.47) | 72.20 | (9.59) | 0.932 | .353 |
| Learning motivation | 21.86 | (3.51) | 21.76 | (3.12) | 0.201 | .841 |
| Planning and implementing | 20.34 | (3.48) | 21.15 | (3.44) | 1.655 | .099 |
| Self-monitoring | 13.99 | (2.55) | 14.58 | (2.33) | 1.715 | .088 |
| Interpersonal communication | 14.76 | (2.14) | 14.70 | (2.31) | 0.165 | .869 |
| Cooperative learning | 59.55 | (6.38) | 58.73 | (6.69) | 0.883 | .378 |
| Learning motivation and attitude | 23.67 | (3.12) | 23.42 | (3.10) | 0.584 | .560 |
| Peer interaction and cooperation | 35.88 | (4.30) | 35.32 | (4.34) | 0.915 | .361 |
| Critical thinking | 60.17 | (8.13) | 60.00 | (8.57) | 0.146 | .884 |
| Open minded | 26.94 | (3.95) | 26.74 | (3.91) | 0.352 | .725 |
| Systemic | 21.95 | (3.30) | 22.18 | (3.21) | 0.496 | .620 |
| Sensitive | 11.29 | (1.99) | 11.08 | (2.09) | 0.714 | .476 |
Table 2
| Parameters | B | 95 % CI | p | |
| Lower | Upper | |||
| SDL | ||||
| Intercept | 72.198 | (70.337, | 74.059) | < .001 |
| TBL | −1.259 | (−3.894, | 1.376) | .349 |
| T 1 | 0.297 | (−1.102, | 1.696) | .677 |
| T 2 | 0.564 | (−0.909, | 2.037) | .453 |
| TBL* T 1 | 4.683 | (2.744, | 6.621) | < .001 |
| TBL* T 2 | 3.895 | (1.918, | 5.872) | < .001 |
| Cooperative learning | ||||
| Intercept | 58.733 | (57.434, | 60.031) | < .001 |
| TBL | 0.818 | (−0.988, | 2.625) | .375 |
| T 1 | 0.119 | (−0.999, | 1.236) | .835 |
| T 2 | 0.703 | (−0.507, | 1.913) | .255 |
| TBL* T 1 | 4.198 | (2.552, | 5.843) | < .001 |
| TBL* T 2 | 2.399 | (0.683, | 4.114) | .006 |
| Critical thinking | ||||
| Intercept | 60.000 | (58.336, | 61.664) | < .001 |
| TBL | 0.173 | (−2.136, | 2.483) | .883 |
| T 1 | 0.594 | (−0.632, | 1.821) | .342 |
| T 2 | 1.495 | (0.277, | 2.713) | .016 |
| TBL* T 1 | 2.324 | (0.492, | 4.156) | .013 |
| TBL* T 2 | 2.372 | (0.537, | 4.208) | .011 |
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