A way forward: Teaching lens for embedding 4C’s in 21st century learning for future Physiotherapy Graduates Education

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This article is currently under peer review and has not yet been accepted for publication. While it may still be referenced at this web address, please bear in mind that amendments to the article may occur as a result of the review process.


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?”


This was a challenging review for me as I am left with many questions for the author. We are all faced with teaching our students 21st century skills that extend beyond discipline theoretical knowledge, skills and attitudes and thus exploring novel ways to get students to value teamwork, become more creative, more critically aware, become and remain inquisitive etc. Blended learning, team-based and problem-based learning etc. are well described methods that may assist in facilitating the development of these critical skills.

I also note the challenge the author faced with introducing change and applaud her talking the plunge in implementing a hybrid TBL strategy in her own teaching, despite faculty resistance.

I have however some concerns with how this article has been written, leaving me with many questions for the author:

Firstly the introduction lacks focus and is confusing. There is too much reporting on albeit relevant pedagogy, but how exactly TBL embeds all these pedagogies remains unclear. What is TBL, how it compares with other similar methods such as PBL for e.g. should be discussed to motivate why the author selected this in her teaching. The author refers to 21st century learning as well as learning 21st century skills – these are two very distinct concepts. Did she select a hybrid mode to ‘keep up with how the new generations want to learn’ or is the focus on developing critical skills?

There is no description of concepts e.g. readiness assurance tests – I am assuming this is a quiz that aims to determine readiness to continue with the next phase? It is also unclear what and or how the team readiness assurance  test was conducted – and what the purpose thereof was. What did the 10 min lecture consist of – was it in response to the team discussion? And what exactly did they discuss. Was the case presented as part of the pre-activity?

Students completed team discussions, compiled a presentation to the class, completed a mini-test and a survey – all within 60min? Followed by students developing an artifact that demonstrate their understanding of the core component/concepts. I am left wondering whether content examples will not make it easier to follow this process. I am also left wondering what the outcome of this was on their understanding and or if more time was spent on understanding the technologies to create the artifacts. How many choose which method?

I am also not familiar with the method of awarding best work – kindly explain this. In your opinion did awarding the best students impact the process e.g. improve engagement.

Re lessons learnt – I agree that the biggest challenge is faculty development in T&L methodologies – there are better strategies for promoting 21st century skills while learning discipline specific content. There were almost a third of students though that did not like this method – what will you do differently to ensure all students benefit from the experience or embrace it more moving forward?

Recommendations for a revised draft:

  1. Be specific in what your reasons for and aims were for introducing this model and clear on what you surveyed amongst the students concerning this approach.
  2. Explain your hybrid version better – how does it differ from typical TBL and why not PBL for example.
  3. Report more specific or clearly on the student survey outcomes/responses.
  4. Reconsider some of the conclusions, especially no 3 – it is unclear how web-based materials leads to lifelong learning.

General comments: The manuscript focus on important topics such as learning of higher order skills in Physiotherapy Education, and how this is facilitated through a modified Team-Based learning approach. The author should be acknowledged for disseminating these experiences to other teachers and educational leaders in health education. However, the manuscript would benefit of a more nuanced approach to educational designs. Traditional learning designs might also include many of the same active elements. Thus, try to clarify, behind headlines, what is the innovative and novel elements of the current intervention, and what were the most important challenges? The manuscript includes some claims that can hardly be justified, these should be rephrased. With these adjustments, the manuscript clearly has a potential. For more detail, see the below paragraphs.

Title. The title is long and difficult to read. Recommend to not use abbreviations and quotation marks in title.

Abstract. The abstract describes the purpose of the manuscript clearly, which is to describe the case of a flipped classroom educational intervention in under-graduate physiotherapy. Unfortunately, the author applies many abbreviations, which decreases readability. As an example, TBL is not fully written out. What does it stand for? When the reader does not understand TBL, understanding H-TBL is even more difficult.

Introduction. First paragraph is a bit confusing to read as it introduces and mixes several topics and concepts, which might or might not be associated. For example, the link between active learning and Blooms’ Taxonomy needs to be justified. It is not obvious that higher order learning only takes place in an active, collaborative environment. Moreover, the link over to self-directed learning is not obvious, needs to be clarified.

The author refers to the concept of active learning, without this being defined. It can be argued that all types of learning are an active cognitive process, regardless of the teaching format. I would recommend adding a definition, such as the one provided by Bonwell & Eison, 1991.

Second paragraph. What is ‘modern education’? Suggest replacing with higher education. As I read, I would suggest that this paragraph is about Flipped Classroom? If this is the case, I would recommend introducing the model, and thereafter brief description of its potential benefits. Flipped Classroom provides student autonomy and flexibility during preparation. In addition, the pre-classroom activities, allows more advanced, higher order learning taking place in classroom. Nevertheless, these potential benefits rely on a few premisses, which may not be fulfilled.

Third paragraph about Team-Based Learning; author claims that emerging evidence support team-based learning (TBL). I do not think this is necessary justified by the literature on health education, see for example:

River, J., Currie, J., Crawford, T., Betihavas, V., & Randall, S. (2016). A systematic review examining the effectiveness of blending technology with team-based learning. Nurse Educ Today, 45, 185-192. doi:10.1016/j.nedt.2016.08.012.

The case report intends to answer, ‘one big question’. Research-based education means that educators need to consider the evidence for how effective various types of approaches are. On the top of this hierarchy is guidelines and reviews. A case report is on the lower part, as it can only highlight specific topics of interest, recommended for further research. Please consider rephrasing the aim accordingly.

The next three sections about TBL are generally well written and show that the author has in-depth knowledge in this concept. However, I would suggest to merge the sections (Why.., how.. and where to…) into a single section with corresponding paragraphs.

The next section ‘Is there a space….’ is key to the manuscript. Consider renaming to something like ‘TBL in physiotherapy education’ This is probably more useful than asking the question. Suggest starting with a description of how TBL has been used in physio education. What is known? Thereafter, an argument of exactly why this educational approach would fit into the physio curriculum. Does it provide an output that is different than other educational approaches? Why is this key in physio?

The intervention is described in too much detail, without providing contextual information.  Due to the rich detailed description, it is hard to grasp the principal lines of the approach. Questions which remain after reading this section are: what were the links between the lectures (1 and 2)? Was the intervention integrated in the curriculum? Was the intervention part of a course in the curriculum, if so, what were the other elements? ECTS? Type of exam? I would suggest replacing one of the figures with a timeline, displaying the students’ learning process throughout the intervention.

I understand Lessons learned, as a kind of discussion section. Unfortunately, the author digs into too much detail, explaining what worked/did not work in the specific course design. This would strongly limit the generalisability of the findings, to other settings than the present one.

It would be much more interesting to focus on the principal aspects of implementing the model, and its outcomes. What were the consequences in relation to student outcomes/motivation? Mainly on the positive side, or were there also some negative findings? What could be the explanation for this, is it about the educational model, or the fact that huge amount of time was spent planning active learning? Booth? What about teachers’ workload in developing the approach? Normally it is hugely time-consuming first time, but with potential for reuse. Was the course-leader compensated for the time-spending? What about the teacher-role in-classroom, did it differ from trad teaching? These and other similar questions cover topics that is part of the debate surrounding digital learning designs in higher education.

Some of the paragraph in this section starts with promising topics, such as ‘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.’ As previously mentioned, this is an important topic. Thus, in this case more detail could have been provided. How much time was spent? Did he work alone or in teams? Compensation? The typical finding in the literature is that the time-spending is not compensated, an after a while the teacher gets tired of spending leisure-time, and the teaching returns to traditional. This might be due to institutional reward system for teaching.

Another example of a promising debate is the paragraph starting with ‘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’. Although relevant aspects are discussed in the paragraph, I would miss a more critical appraisal of the findings. Could it be that some of the dissatisfied students prefer passive learning practices? From the literature it is known that students used to surface learning get confused when exposed to deep learning. In this debate it would be interesting to know the previous experiences of these students.

The conclusion is not sufficiently justified, given the limitations of the study design etc. I would suggest instead using terms as ‘provide promising…’

In the ‘Implications for future research’ section it is claimed that ‘The experiences of H-TBL in these two cardio-respiratory lectures have significant implications for any future TBL designs on several fronts.’ This is a too strong claim based on the findings. The section should be rewritten and target some key areas for further research with various types of design. For example, would it be beneficial to further investigate the student perceptions in qualitative studies? Would it be possible to investigate the effectiveness of this type of approach in a prospective RCT? There is clearly a need for studies with a robust design to investigate the effectiveness of educational interventions. These are only suggestions.

Conflict of interest statement

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 authors own personal time.

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