A way forward teaching lens for embedding “4C’s” in 21st century learning for future Physiotherapy Graduates Education

Author: Shakila Devi Perumal / Submitted: 12 November 2020

This article is currently undergoing peer review.


In modern education, flipped-blended learning has gained popularity around the globe. However, pedagogical inquiry of what we teach, where we teach, how and how much we blend in face to face (F2F) and online teaching is focused on the account of instructors (lecturer) designing new models of flipped-blended learning at undergraduate physiotherapy courses. This article describes a case report that illustrates why TBL and how hybrid TBL can be used to help undergraduate physiotherapy students (year 2) to understand and improve their ‘4Cs’ – Critical thinking, Communication, Collaboration, and Creativity in a cardio-respiratory disease management topic. This case report intends to answer one big question “Is H-TBL a way forward for 21st-century learning?”


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). 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).  Too 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 inspire students self-directed learning and train attributes of scientific mindset such as curiosity, lifelong inquiry and learning (Madhuri et al., 2012). Recently, report (2019) from knowledge, evidence and learning for development on the ‘Framework for 21st Century Learning’ summons education system to embed the lens of ‘4Cs’ – Critical thinking, Communication, Collaboration and Creativity in any teaching curriculum to prepare students for the demands in professional workforce. 

In this era of technology, modern education is drawn to online learning and instruction, commonly named “Flipped- Blended Learning” to foster active student-centred learning. And rising institutional competition for “Gold” accreditation in Teaching Excellence framework (TEF) had influenced greater influx of student-centred learning notion in the market of University education. Though “Flipped- Blended Learning” in itself presents a massive opportunity for both students and educators, but comes by price of challenges to instructional design paying tributes to pedagogical inquiry of what we teach, where we teach, how and how much we blend in face to face(F2F) and online teaching.  A quote by Mishra & Koehler (2006) “Quality teaching requires developing a nuanced understanding of the complex relationships between technology, content, and pedagogy, and using this understanding to develop appropriate, context-specific strategies and representations” urging reflection on the current teaching practices as “One size does not fit all”. 

Many diverse models of active learning strategy persist among which problem – solving, project-based learning and task-based learning are in everyday practice of some higher education institution (Dolmans et al., 2015). In the last few years, emerging evidence support team-based learning (TBL), a special flipped (blended) instructional design, active learning strategy focused on student-centred collaborative learning with instructor led design, that incorporates specific sequence of individual work, group work and immediate feedback to promote student’s engagement and satisfaction (Sisk, 2011). This article scribes a case report that illustrates why TBL and how hybrid TBL can be used to help physiotherapy student to understand and improve their ‘4Cs’ – Critical thinking, Communication, Collaboration and Creativity in a cardio-respiratory disease management topic. Furthermore, this case report presents the blueprint of the H-TBL design piloted for two cardiorespiratory lectures for year two undergraduate physiotherapy students in one of the Russell Group University in United Kingdom.  This case report intends to answer one big question “Is really H-TBL a way forward for 21st century learning?”

Why TBL?

TBL’s existence traces its roots to Professor Larry Michaelson in 1970, a concept that seeks active collaborative learning partnership between students and educators (Johnson, 2009). TBL design comprises highly structured activities for students accountability and cognitive engagement both in out of classroom work and in-class room collaboration with their peers. It is beyond basic acquisition of facts and fosters complex reasoning through intra and inter group discussion on real life scenarios stimulating transformation of a novice learner to an expert in a non-threatening ambience. TBL promotes self-efficacy in students learning to process and stimulates enthusiasm in team work building professionalism skills (Loftin and West, 2017). TBL design and delivery sequence supports Kolb’s learning style, a cyclic process of real experience- reflection- active experimentation- abstract formation creating an environment for engagement for revival and retrieval of information (Mcleod, 2017).

How to prescribe TBL?

The three critical elements for prescription and successful TBL implementation (Michaelson and Sweet, 2008) to any course regardless of class size include:

  1. Student Accountability – Students held accountable for knowledge acquisition, creating a community of inquiry
  2. Student Interactivity – Students inter and intra team discussion with prompt feedback promotes a community of practice within a discipline
  3. Task Design: The framework for task design adheres to the “4S” principle: A diligent task design around a “Significant” problem with a focus on the “Same” question, with “Specific” choice, and students are reporting “Simultaneously” their answers/ views to the whole classroom for immediate feedback

Basic sequence of TBL design and delivery comprises 3 phases:

  • Phase 1 (Outside classroom): Pre-class Preparation
  • Phase 2 (In-classroom): individual and team Readiness Assurance Test (iRAT and tRAT)
  • Phase 3 (In- classroom): Knowledge Application Exercises

Where do we go from here?

Many courses have implemented a modified version of TBL with adherence to protocol of readiness assurance test (RAT) and application exercises to promote student interactivity and community of practice (Burgess et al., 2014; Haidet et al., 2014; Wenger 2010). A plethora of evidence affirms TBL enhances higher order skills, self-efficacy, teamwork, and academic performance (Branson et al., 2016; Clark et al., 2008; Fatmi et al., 201; Haidet et al., 2014; Reimschisel et al., 2017). Despite its proven benefits, TBL has a strong foothold in healthcare education especially in medical and nursing education in the United States compared to the United Kingdom (Khogali et al., 2013). In resonance, two studies in nursing education, one, a randomised trial (Kim et al., 2016) demonstrated use of TBL in respiratory management course improved student’s problem-solving ability, knowledge and clinical performance significantly compared to traditional lectures and the other observational study (Branney and Priego-Hernández, 2018) conferred use of TBL in pathophysiology teaching for nursing students improved their accountability and satisfaction to the course. Despite its proven benefits, to author’s knowledge there is little evidence of TBL use in physiotherapy education (Amorim et al., 2019; Lein et al. 2017; Livingston et al., 2014).

Is there a space for TBL in Physiotherapy Higher Education Delivery?

A Hybrid Team Based Learning design was piloted in 2 lectures (2019 & 2020) of undergraduate cardio-respiratory physiotherapy module. Hybrid -TBL relates to the design of lecture and virtual case challenge introduced in web-based as pre- class individual work followed by on campus readiness assurance test and application exercise with immediate feedback creating a “Zone of possibility” for  proximal development and equilibration of new knowledge.

Lecture 1: In 2019 (November), a keynote lecture on Chronic Obstructive Pulmonary Disease (COPD) was taught using a novel “hybrid team-based learning” (H-TBL) comprising phases 1-4, delivered in two sessions to year two (n=136), undergraduate physiotherapy students. The design and sequence of H-TBL delivery were aligned to Bloom’s Taxonomy and Kolb’s experiential learning style as illustrated in Figures 1 and 2.

Figure 1

Figure 2

Phase 1- Section 1

Section 1 -Phase 1 (Pre-class individual work): This section featured an online course content on basics, concepts and evidence-based practice relevant to the topic – “COPD”. To foster individual scaffolding of knowledge equilibration, a virtual case challenge using a problem-solving model with formative individual readiness assurance test (iRAT) was introduced at the end section 1. The iRAT had no grades or rewards assigned for the test. Students were informed it is pre-requisite to complete Section 1 to attend the Section 2 on campus. Students were informed on the duration of learning time was approximately 40-60 mins to allow timely engagement in the content. This section gave students a pre-context of the subject and their readiness to explore deeper learning in Section 2.

Phase 2-4- Section 2

Section 2 (Critical reflection): This section featured Phase 2 (Team Readiness Assurance Test-tRAT) and Phase 3 (Application Exercise) both on campus session designed to build in depth knowledge on the pre-class work. This section was scheduled for 60 mins and commenced with rules of engagement, team readiness assurance test (tRAT) promoting verbal appeal with immediate feedback followed by brief ten minutes presentation by lecturer on the subject. Following, teams were reshuffled in small teams for peer discussion and peer presentation from each team to whole class cohorts adhered to the 4S principle of TBL. This was followed by mini test and student survey. Pedagogically in this section, the lecturer wanted to create an intellectually active environment for student engagement that fosters collaborative communication in small teams, constructive conflict, synthesis of concepts and equilibration of new ideas. At the end of the classroom session, phase 4 (outside class work) was added, delegating creative assignment to students on a relevant common theme to test their knowledge equilibration and consolidation. Student were given autonomy on presenting their assignment in a creative form of either a power point (max slides 5), blog (max 50 words) or infographics within 9-10 days following the Section 2 . Students were informed two best work would be rewarded.

Lecture 2: In 2020 (February), a key note lecture on Pulmonary rehab taught using same design novel “hybrid team-based learning” (H-TBL) comprising only phases 1-3, delivered in two sessions to our year two (n=136) undergraduate physiotherapy students.

Phase 1- Section 1 & 2

Section 1 – This section comprises basics, concepts and evidence-based practice relevant to Pulmonary rehabilitation. Learning time was allocated approximately for an hour and 30 mins to complete this section.

Section 2 (Reflective learning): This section featured virtual case study challenge on pulmonary rehabilitation to enhance understanding of subject content with interactive reward points in University learning management system (Blackboard). Learning time was allocated for approximately 20 mins to complete the section. Students were informed it is pre-requisite to complete both sections to attend the session on campus.

Phase 2 & 3

On campus session: This section featured the same design of Phase 2 and Phase 3 of Lecture 1 (COPD) but the content was related to pulmonary rehabilitation. Due to time constraints student survey was not captured. There was no creative task assigned considering students workload demands for clinical placements and research proposal during the time of this lecture in year 2020.

What was the response of students for H-TBL?

In Lecture 1, of 136 students, 82% engaged in Phase 1, 80% attended the Phase 2 and 3 of COPD 2 session, and 74% engaged in phase 4. 72% provided their perception (anonymised) on their learning experience captured through online polling “Mentimeter” word cloud. There was significant response of student engagement with mind-blowing creative works. And five students were awarded best work. In total, 54/ 75 (72%) students provided feedback on the session. Examples of students’ feedback include “Vibey, Interactive, Energetic, Engaging, Informative, Creative, Good, Friendly, Fun, Unique and Love Group Work.” In contrast, a small group of students recorded “Wanted to have a lecture, Better as a tutorial, No structure and Confusing.”

In Lecture 2, of the 136 students, 84% attended  and engaged in the Phase 2 & 3 of H-TBL. Prior to on campus session, a midway data on student engagement to online case challenge confirmed 42% of students completed both section 1&2 of Phase 1.

Lessons Learned

First, the introduction of web-based course content with virtual case challenge in both lecture 1 & 2, prior to the classroom session attracted authentic student accountability and engagement in success of the learning objectives. This allowed student’s preparedness and confidence for deep learning of relevant subject.

Second, team readiness assurance test (tRAT) ensured student understanding from the pre class individual work. This facilitated a meaningful use of class time for assessment and application of knowledge “to process information at highest cognitive complexity” (Parmelee & Hudes 2012).

Third, in on campus session (phase 2 and 3) a clear instruction on rules of engagement for application exercise including peer discussion and presentation had placed a social constraint on students interpersonal and team engagement skills of being respectful, active listener in constructive conflict with their peer during inter and intra teams’ interactions.

Fourth, presenting a real-world practice challenge and inviting a different perspective though daunting for student, instructor was impressed by the quality of presentations and ideas during phase 3 in both Lecture 1 and 2. This assures students value the experience of critical inquiry and communication in a collaborative learning with their peers and promotes sticky “lifelong learning” (Garrison et al 2000).

Fifth, the completion of creative assignment challenge in Lecture 1 revealed students’ talents of creativity, innovation, self-efficacy and ownership for knowledge acquisition though it was informed this assignment does not count summative assessment of the module. The author believes the introduction of incentive for creative assignment had opened the channels of enthusiasm and a collegiate competition among students in lecture. Sadly, due to student workload the incentive phase was not introduced in Lecture 2 and author believes this might have constraints in their mental processing and deeper engagement in the relevant content.  

Sixth, designing and implementation of the pre-course content both web -based and lesson plan for the on-campus session was demanding a huge workload from lecturer. This new model of H_TBL piloting, bounded one side by the content and pedagogy, and constrains of logistics scheduling of the module and workload of students, there was a need for lecturer’s “situation creativity” centred on the principles of design thinking and pedagogical responsiveness. The author here wants to acknowledge the assistance of learning technologist for best laid plan to tackle the constrains and nuance that had gained success in implementation of H-TBL. As unique context of hydrid -instruction design provides challenges to teaching and learning, it is undeniable fact that lectures need to be flexible and purposeful problem solvers with appropriate pedagogically sound solutions.

Seventh, though majority of students embraced the deep learning opportunity created by H-TBL design, whilst a small percentage of 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. 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 time management skills (Atwa et al., 2019; Ghorbani et al., 2014; Livingston et al., 2014). In accordance with experiential learning theories, some students relate 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).

Eight, a pinnacle of challenge was 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, 2013; Karaman & Sari, 2020). Some perceived barriers by lecturers for active teaching are insufficient time, limited resources, a lack of departmental support, concerns about content coverage, concerns about evaluations of their education, and student’s resistance to engage with their peers (Deslauriers et al., 2019). This behaviour and perceptions of lectures demands key attention on quality assurance of professional development training programmes on pedagogical content and teaching practices.

In conclusion, this case report illustrates H-TBL can foster self-regulated active learners, with 21st 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.

Implications for future research

The experiences of H-TBL in these two cardio-respiratory lectures have significant implications for any future TBL designs on several fronts.

First, to widen student engagement, a clear communication on learning strategies for every lecture should be recorded in the student handbook to relinquish the control and management of student ownership to active learning.

Second, to control time commitments for students, creating a living physiotherapy curriculum with learning contracts could appeal to diverse individual learning styles.

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 as part of professional development programme would enhance co-operation and confidence among lectures team 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.

Take home message

1. H-TBL design supports 21st century students learning with ‘4Cs’ – Critical thinking, Communication, Collaboration and Creativity skills.

2. H-TBL design supports significant student’s cognitive engagement, accountability and self-efficacy.

3. Web-based materials serve as a springboard for students recall and retention for lifelong learning process.


The author would like to acknowledge the support from both Ms. Rebecca Potton, learning technologist, School of Healthcare Sciences and Mr. Owen Crawford, learning technology officer, Centre for Education support and innovation, Cardiff University 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. Michael Rowe, Associate Professor and the Departmental Chairperson of Physiotherapy at UWC for critical peer review to add more clarity to this case report.

Declaration of interest

The author reports no conflict of interest. The author is solely responsible for the content and writing of the article. No funding received and article produced in author’s personal time.

Funding/Support: No funding. This case-report is produced in author’s own personal time.


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