Team-based learning in health professions education: an umbrella review

Abstract

Background

Team-Based Learning (TBL) has garnered considerable attention in education research. To consolidate the existing evidence, we conducted an umbrella review with four objectives: ^(a) to identify TBL review characteristics, ^(b) to synthesize findings from previous reviews regarding TBL effectiveness and outcomes, ^(c) to determine which student groups benefit most, and ^(d) to identify the most and least researched elements.

Methods

The Joanna Briggs Institute (JBI) methodology was followed: [1] Search strategy and literature search [2] Screening and Study Selection [3] Assessment of methodological quality [4] Data collection, and [5] Data summary. We utilized Endnote, Excel, and MAXQDA for efficient project management and analyzing data.

Results

Analyzing twenty-three reviews spanning from 2013 to 2024, we found a peak in TBL research in 2022 including more than 312 unique primary studies involving more than 63,987 participants. Notably, the United States and China accounted for over 61% of the total primary articles focused on students from medicine, nursing, pharmacy, and dentistry. Evidence supports the superiority of TBL in enhancing cognitive outcomes. However, findings related to retention are mixed. Insufficient evidence exists to draw robust conclusions when comparing TBL with other active learning methods. TBL demonstrates favorable outcomes in terms of clinical performance and engagement. Non-technical skills show mixed results. Notably, TBL positively impacts self-study, learning ability, decision-making, and emotional intelligence. Faculty experiences reveal an initial increase in workload, but generally hold positive attitude. Faculty development remain limited in duration and scope. Freshmen, academically weaker students, undergraduates, Chinese female students, and nursing students appear to benefit most from TBL. Team formation and size are the most frequently studied elements.

Conclusion

TBL holds promise for improving learning outcomes, but ongoing investigation is essential to maximize its impact in diverse educational contexts. This umbrella review underscores the need for further research in specific areas i.e. effective pre-class learning methods and faculty workload.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-024-06147-x.

Background

TBL is an active learning instructional strategy with three specific phase including advance preparation, individual and team readiness assurance tests and application phase [1]. It was developed in the 1980s in the US by Larry Michaelsen, for business school courses [2]. In 2004, with funding from the US Department of Education, medical schools in the US began to implement it to reduce lecture hours [3, 4], soon followed by nursing schools [5–11]. Many Health Professions Education (HPE) programs across the globe since 2010 have used TBL in various disciplines and education levels. Although extensively studied since introduced by HPE programs, there is debate about the effectiveness of TBL in improving learner outcomes compared to traditional teaching and learning strategies. For example, there is mixed evidence on the impact of the strategy on student satisfaction [12]. Koles et al. (2010) [13], Zgheib et al. (2011) [14], and Thomas et al. (2011) [15].

Since considerable resources are required to conduct TBL correctly and well, the effects of this strategy on student learning (cognitive and non-cognitive) must be characterized. Fortunately, researchers have conducted systematic reviews and meta-analyses on primary studies of TBL to identify factors that either enhance or impede the learning process.

In 2013, Fatmi et al. [12] published a Best Evidence Medical Education (BEME) systematic review on the effectiveness of TBL on learning outcomes in medical education. The findings of this study included improved knowledge scores but ambivalent student satisfaction largely centered around the work preparatory work required and the emphasis on accountability and use of peer evaluation. The authors further noted lack of investigation of TBL’s benefits for critical thinking, decision-making, problem-solving development. Joshi et al. in a systematic review on the effectiveness of TBL in HPE mentioned the exponential increase in the number of studies published on TBL and need for further research on other aspects [16].

Moreover, Haidet et al. in their review questioned the methodology of reporting TBL interventions and proposed a reporting guideline [17]. Mark Gera et al. examined the effects of TBL on learner process outcomes (i.e. critical thinking skills development) and reported the need for evidence on motivation and clinical problem solving [18]. Furthermore, Tyler Reimschisel et al. concluded that despite extensive studies on the educational impact of TBL, important dimensions such as teacher decisions about TBL, contextual factors, learners’ engagement, and pattern of engagement within teams have been overlooked [19]. As of mid-2024, there have been about twenty reviews (systematic and scoping) with most reporting on the effectiveness of TBL on student satisfaction, academic performance, and process outcomes such as the development of critical thinking or student engagement. Overall, most are classified as systematic reviews.

We selected an umbrella review (UR) strategy also name as a deep look of reviews, reviews of reviews, summaries of systematic reviews, and syntheses of reviews to systematically consolidate the findings and knowledge gaps of the many systematic reviews of TBL [20]. Such a holistic approach intends to brings coherence to the evidence supporting the research questions and to identify conflicting or divergent results thereby providing opportunity to understand the reasons for discrepancies. The systematic synthesis of existing systematic reviews and meta-analyses offers a expeditious means of comprehensively evaluating the breadth of evidence pertaining to a particular subject matter. An umbrella review of TBL is particularly advantageous for presenting a synthesis of the evidence and gaining insights into the nuances and complexities associated with TBL research [21].

Research questions

Within this umbrella review, we address these research questions:

RQ1: What are the TBL review characteristics?

RQ2: What are the findings of previous reviews on effectiveness and outcomes of TBL?

RQ3: What groups have benefited the most from TBL?

RQ4: What are the most and least researched TBL elements in reviews and what are the under-studied areas in general?

Inclusion criteria

The PIOS (Population, Intervention, Outcomes, and Study design) framework shaped the inclusion criteria. The Population included health professions trainees (i.e., medicine, nursing, dentistry, pharmacy, allied health disciplines). Phenomena of interest/intervention are reviews focusing on TBL Outcomes also focused on these four issues:

• TBL review characteristics.

• Findings of previous reviews on effectiveness and outcomes of TBL.

• The learner populations that have benefited the most from TBL.

• The most and least researched TBL topics found in reviews.

It is worth mentioning this umbrella review included systematic reviews with or without meta-analyses and scoping reviews. By including both systematic reviews and scoping reviews, this umbrella review captures the strengths of these two methodologies. The systematic reviews provided rigorous and evidence-based synthesis, while the scoping reviews offered a broader perspective and identified the breadth of available literature. This comprehensive approach insures a comprehensive analysis of the existing evidence on TBL.

Methods

This umbrella review was conducted according to the JBI methodology [22] and was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [23].

Search strategy and literature search

We comprehensively searched Ovid MEDLINE(R) ALL, Embase (Ovid SP), APA PsycInfo (Ovid SP), CINAHL Plus with Full Text (EBSCOhost), Scopus, and Web of Science Core Collection (Science Citation Indexed-Expanded, Social Science Citation Index, and Emerging Source Citation Index) from inception until 5 August 2023 with no time or language restrictions. We updated our search strategy on 19 February 2024 (See Appendix A).

Screening and study selection

The retrieved records were entered into EndNote V.21, and the duplicates were removed. Two reviewers (MA and AN) independently screened the title and abstract and then the full text of the studies based on the inclusion criteria. The discrepancies that arose have been resolved upon the entry and implementation of the third party’s (RM) opinion.

Assessment of methodological quality

In this study, the methodological quality of each included review was critically appraised using JBI critical appraisal checklist for systematic reviews and research syntheses [24] to critically appraise the methodological quality of each included review. To conduct the critical appraisal, an Excel spreadsheet was created, wherein each checklist item was allocated to a separate column. Two independent reviewers (RM and AN) were responsible for assessing the articles. In the event of any disagreements between the reviewers, a third party’s perspective (MA) was sought and applied to resolve the discrepancies. Quality appraisal results of twenty-three articles included in this umbrella review is shown in Table 1.

Table 1.

Quality appraisal of articles included in umbrella review

	Is the review question clearly and explicitly stated?	Were the inclusion criteria appropriate for the review question?	Was the search strategy appropriate?	Were the sources and resources used to search for studies adequate?	Were the criteria for appraising studies appropriate?	Was critical appraisal conducted by two or more reviewers independently?	Were there methods to minimize errors in data extraction?	Were the methods used to combine studies appropriate?	Was the likelihood of publication bias assessed?	Were recommendations for policy and/or practice supported by the reported data?	Were the specific directives for new research appropriate?	Overall appraisal
James Trill et al., 2024 (35)	Yes	Yes	Yes	Yes	Unclear	Yes	Unclear	Unclear	Not applicable	Yes	Yes	Include
Sterpu et al., 2024 (36)	Yes	Yes	Yes	Yes	Unclear	Yes	Unclear	Unclear	Not applicable	Yes	Yes	Include
Zhang et al., 2023 (33)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Not applicable	Yes	Yes	Include
M. M.-Y. Yeung et al., 2023 (38)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Not applicable	Yes	Yes	Include
Chytas et al., 2023 (32)	Yes	Yes	Yes	Yes	No	No	No	Unclear	Not applicable	Unclear	Yes	Seek further info
Joshi et al., 2022 (16)	Yes	Yes	No	Yes	Yes	Unclear	Yes	Yes	Not applicable	Yes	No	Include
Methaneethorn & Methaneethorn, 2022 (34)	Yes	Yes	Yes	Yes	No	No	Yes	Unclear	Not applicable	Yes	No	Include
Wang et al., 2022 (31)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Include
Bingjie et al., 2022 (30)	Yes	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	Yes	Yes	Yes	Include
Burgess & McGregor, 2022 (43)	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Not applicable	Yes	Yes	Include
Considine et al., 2021a (42)	Yes	Yes	Yes	Yes	Not applicable	Not applicable	Unclear	Yes	Not applicable	Yes	Yes	Include
Considine et al., 2021b (29)	Yes	Yes	Yes	Yes	Not applicable	Not applicable	Yes	Yes	Not applicable	Yes	Yes	Include
Alberti et al., 2021 (28)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Not applicable	Yes	Yes	Include
Ngoc et al., 2020 (39)	Yes	Yes	Unclear	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Include
Lang et al., 2019 (26)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Include
Swanson et al., 2019 (27)	Yes	Yes	Unclear	Yes	No	No	Yes	Yes	Yes	Yes	Yes	Include
Chen et al., 2018 (25)	Yes	Yes	Unclear	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Include
Dearnley et al., 2018 (37)	Yes	Yes	Yes	Yes	Yes	Unclear	Unclear	Yes	Not applicable	Yes	Yes	Include
Reimschisel et al., 2017 (19)	Yes	Yes	Unclear	Yes	No	No	Yes	Yes	Not applicable	Yes	Yes	Include
River et al., 2016 (40)	Yes	Yes	Unclear	Yes	Yes	Yes	Yes	Yes	Not applicable	Yes	Yes	Include
Haidet et al., 2014 (17)	Yes	Unclear	Unclear	Yes	No	No	Unclear	Unclear	Not applicable	Yes	Yes	Seek further info
Burgess et al., 2014 (41)	Yes	Yes	Unclear	Yes	Yes	Yes	Unclear	Yes	Not applicable	Yes	Yes	Include
Fatmi et al., 2013 (12)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Not applicable	Yes	Yes	Include

Data collection

In this step, the items of the JBI data extraction tool [24] were entered into an Excel spreadsheet. However, it is important to note that modifications were made to the tool to align it with the specific questions and objectives of the umbrella review. Two independent reviewers (MA and AN) were responsible for extracting data from each review. Their independent efforts ensured a thorough and reliable extraction process, minimizing the potential for bias and enhancing the overall validity of the findings.

Data summary

The quantitative data collected in this study were entered into Excel software for further analysis. This involved organizing the data and generating tables and graphs to present and summarize the findings. The use of Excel software facilitated efficient data management and enabled the visual representation of key quantitative patterns and trends. Additionally, for the qualitative component of the analysis, MAXQDA 2020 software was employed. This software facilitated the process of qualitative content analysis, allowing for systematic and rigorous examination of the data in relation to the research questions. Through MAXQDA 2020, the qualitative data were coded, categorized, and analyzed to identify themes, patterns, and insights that emerged from the data.

Results

Figure 1 Shows the PRISMA diagram of selecting scoping and systematic reviews screening process as well as justifications for our rejections. We found 581 articles based on the database search string. After removing duplicates, 225 records remained. 181 records were excluded after title and abstract screening and 44 records were downloaded for full text review. Two researchers then read articles independently and identified 21 articles that met the criteria. Discrepancies on the selection were resolved by discussion. It should be noted that during the project and after updating the search strategy, it was found that 3 new systematic reviews were published. After the critical appraisal of these three articles by two independent researchers, one of them was removed and the remaining two articles were added to the study. Finally, this umbrella review entered the data collection stage with 23 articles.

Fig. 1.

The PRISMA diagram

RQ1: what are the TBL review characteristics?

The results of this umbrella review were categorized based on reviews which were conducted on TBL in health professions education. Findings were categorized by publication year, geographic distribution, target discipline. Furthermore, data extracted from reviews included in this umbrella review in terms of type of reviews, adherence to reporting guidelines, years of search strategy, searched databases, and objectives of reviews and characteristics of learners in primary studies are presented in supplementary appendix B.

After identifying 23 articles, it was evident that a total of 312 primary articles were referenced for writing these papers. Table 2; Fig. 2 illustrates the geographical distribution (continent/country) of TBL primary published articles in health professions education. Most of the published TBL articles (n = 144) conducted in the American continent (134 USA, 1 Mexico, 2 Brazil, 1 Colombia, 6 Canada). After America, 136 of published articles carried out in Asia (58 China, 2 Indonesia, 2 Hong Kong, 5 Saudi Arabia, 20 South Korea, 1 Thailand, 10 Iran, 6 Japan, 5 India, 1 Pakistan, 3 Turkey, 5 Lebanon, 4 Oman, 1 Jordan, 4 UAE, 4 Taiwan, and 5 Singapore). Then Europe (n = 15; 2 Italy, 1 Finland, 1 Denmark, 1 Switzerland, 4 Germany, 1 Austria, 5 England), and Australia (n = 13) had the highest number of articles assessing TBL in health professions education. Four of the reviews were published in Africa (1 Sudan, 1 Egypt, 1 Zimbabwe, 1 Tanzania). Subsequent investigations uncovered that a significant majority, 90%, of the primary articles were sourced from America and Asia, with the remaining three continents contributing to merely 10% of the articles. Notably, the United States and China accounted for over 61% of the total primary articles, indicating their substantial contribution to the literature on TBL. This finding suggests a geographical concentration of research efforts in America and Asia, particularly the United States and China, regarding TBL.

Table 2.

Country of origin of primary studies included in TBL reviews

Continent	Country	Number of records	Number of articles per country (After removing duplicates)	Percent	Number of articles per continent	Percent
America	USA	240	134	42/9%	144	46%
	Mexico	1	1	0/3%
	Brazil	4	2	0/6%
	Colombia	2	1	0/3%
	Canada	7	6	1/9%
Australia	Australia	30	13	4/2%	13	4%
Africa	Sudan	1	1	0/3%	4	1%
	Egypt	1	1	0/3%
	Zimbabwe	1	1	0/3%
	Tanzania	2	1	0/3%
Asia	China	65	58	18/6%	136	44%
	Indonesia	2	2	0/6%
	Hong Kong	4	2	0/6%
	Saudi Arabia	6	5	1/6%
	South Korea	49	20	6/4%
	Thailand	2	1	0/3%
	Iran	22	10	3/2%
	Japan	11	6	1/9%
	India	5	5	1/6%
	Pakistan	1	1	0/3%
	Turkey	5	3	1/0%
	Lebanon	11	5	1/6%
	Oman	8	4	1/3%
	Jordan	1	1	0/3%
	UAE	6	4	1/3%
	Taiwan	11	4	1/3%
	Singapore	12	5	1/6%
Europe	Italy	3	2	0/6%	15	5%
	Finland	1	1	0/3%
	Denmark	1	1	0/3%
	Switzerland	1	1	0/3%
	Germany	6	4	1/3%
	Austria	6	1	0/3%
	England	8	5	1/6%

Fig. 2.

The publication dates, types of included reviews and distribution of reviews in scientific journals

As shown in Table 3, the target discipline of learners was summarized. The studies targeted various groups of learners: Medicine (127/312; 40.71%), Nursing (63/312; 20.19%), Pharmacy (47/312; 15.06%), Dentistry (23/312; 7.37%), Residency (8/312; 2.56%), Physical therapy (4/312; 1.28%), Physician Assistant (2/312; 0.64%), Public Health (2/312; 0.64%), Rehabilitation (1/312; 0.32%), Psychiatric (1/312; 0.32%), Exercise Physiology (1/312; 0.32%), Microbiology (1/312; 0.32%), Midwifery (1/312; 0. 32%), other health professions education (13/312; 4.17%). 5.77% (n = 18) reviews involved more than one group of students. The distribution of academic disciplines within the utilized primary studies reveals an imbalance in statistics. Specifically, approximately 84% of the primary studies included in the 23 articles focused on students from four clinical fields: medicine, nursing, pharmacy, and dentistry. This statistic underscores the predominant attention given to the TBL within clinical disciplines in the field of medical sciences. The finding indicates that TBL has garnered significant interest and application within clinical fields, while its utilization in non-clinical domains or basic science disciplines appears to be comparatively limited.

Table 3.

Distribution of primary articles used in TBL reviews based on target disciplines

	Medical Education	Nursing Education	Pharmacy Education	Dental Education	Residency Education	Physical Therapy	Physician Assistant	Public Health	Rehabilitation students	Psychiatric educators	Exercise Physiology	microbiology	Midwifery students	More than 1 field	Others	All
James Trill et al., 2024 (35)				5												5
Sterpu et al., 2024 (36)	49															49
Zhang et al., 2023 (33)		10														10
M. M.-Y. Yeung et al., 2023 (38)		6														6
Chytas et al., 2023 (32)	4					1	1									6
Joshi et al., 2022 (16)	17	5	1	2	5	2			1					3		36
Methaneethorn & Methaneethorn, 2022 (34)	1		6													7
Wang et al., 2022 (31)				12												12
Bingjie et al., 2022 (30)	12															12
Burgess & McGregor, 2022 (43)	1		2					1						7	1	12
Considine et al., 2021a (42)	1	41					1							2		45
Considine et al., 2021b (29)	1	38					1							1		41
Alberti et al., 2021 (28)		12														12
Ngoc et al., 2020 (39)	3	3	1	2				1						1		11
Lang et al., 2019 (26)			12													12
Swanson et al., 2019 (27)	14		9		1				1			1		1	3	30
Chen et al., 2018 (25)	13															13
Dearnley et al., 2018 (37)		16														16
Reimschisel et al., 2017 (19)	52	19	22	5	6	3	1	1	1	1	1		1	5		118
River et al., 2016 (40)	4	1	4													9
Haidet et al., 2014 (17)	16	3	8		2			1						1	9	40
Burgess et al., 2014 (41)	20															20
Fatmi et al., 2013 (12)	8	1	3	1											1	14
Number of records	216	155	68	27	14	6	4	4	3	1	1	1	1	21	14	536
Number of records after removing duplicates	127	63	47	23	8	4	2	2	1	1	1	1	1	18	13	312
Percent	40/7%	20/2%	15/1%	7/4%	2/6%	1/3%	0/6%	0/6%	0/3%	0/3%	0/3%	0/3%	0/3%	5/8%	4/2%

The publication dates of the 19 extracted articles ranged from 2013 to 2024. In 2013–2016, four articles, in 2017–2020, six article, and then from 2021 to 2024, that number grew to thirteen. Of 23 review studies included in this umbrella review, four were designated as scoping reviews, one as meta-analysis, 13 as systematic reviews, three of which integrated a scoping review/systematic review with meta-analysis. In Table 4, the overlap of the resources mentioned in the review studies is presented.

Table 4.

Overlaps in the reviews

		1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21	22	23
James Trill et al., 2024 (35)	1
Sterpu et al., 2024 (36)	2	0
Zhang et al., 2023 (33)	3	0	0
M. M.-Y. Yeung et al., 2023 (38)	4	0	0	0
Chytas et al., 2023 (32)	5	0	0	0	0
Joshi et al., 2022 (16)	6	0	9	1	0	0
Methaneethorn & Methaneethorn, 2022 (34)	7	0	0	0	0	0	0
Wang et al., 2022 (31)	8	0	0	0	0	0	0	0
Bingjie et al., 2022 (30)	9	0	0	0	0	0	0	0	0
Burgess & McGregor, 2022 (43)	10	0	0	0	0	0	0	0	0	0
Considine et al., 2021a (42)	11	0	0	3	2	1	1	0	0	0	0
Considine et al., 2021b (29)	12	0	0	3	2	1	1	0	0	0	0	38
Alberti et al., 2021 (28)	13	0	0	0	2	0	0	0	0	0	0	19	9
Ngoc et al., 2020 (39)	14	0	2	0	0	0	3	0	0	0	1	4	2	1
Lang et al., 2019 (26)	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Swanson et al., 2019 (27)	16	0	5	0	0	0	5	2	0	0	0	0	0	0	0	0
Chen et al., 2018 (25)	17	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Dearnley et al., 2018 (37)	18	0	0	1	1	0	0	0	0	0	0	12	15	6	0	0	0	0
Reimschisel et al., 2017 (19)	19	3	14	0	0	1	13	3	0	0	1	16	14	4	3	0	24	0	10
River et al., 2016 (40)	20	0	0	0	0	0	0	1	0	0	0	1	1	0	0	0	1	0	0	3
Haidet et al., 2014 (17)	21	0	3	0	0	0	3	1	0	0	0	2	2	0	0	0	12	0	2	26	1
Burgess et al., 2014 (41)	22	0	5	0	0	1	3	0	0	0	0	0	0	0	0	0	9	0	0	17	1	8
Fatmi et al., 2013 (12)	23	0	2	0	0	0	3	1	0	0	0	0	0	0	0	0	11	0	0	12	1	8	6

Findings of the umbrella review:

An analysis of 23 articles published in various journals using Scimago Journal & Country Rank revealed that most of the articles (69.5%, or 16 out of 23) appeared in Q1 journals. A smaller percentage (8.8%, or 2 out of 23) were published in Q2 journals, and the same proportion appeared in Q3 journals. Additionally, 13% of the reviews (3 out of 23) were not indexed on the SJR website and did not receive a ranking in any Q category (as shown in Fig. 3).

Fig. 3.

Country of origin of primary studies

RQ2: what are the findings of previous reviews on effectiveness and outcomes of TBL?

A-1: Cognitive Outcomes Compared with Lecture.

Short term learning

The cognitive outcomes of TBL in the short term, particularly in comparison to Lecture-Based Learning (LBL), emerged as one of the most extensively studied aspects in the reviewed literature. The evidence consistently supported the superiority of TBL in enhancing students’ cognitive performance. Among the 23 reviews analyzed, 17 reviews (74%) reported on the cognitive outcomes of TBL. Out of these 17 reviews, 13 (76.5%) compared TBL with LBL, while 3 reviews (23.5%) reported cognitive outcomes without mentioning a specific comparator. The findings across these studies were consistent and unequivocal. Students performed better in theoretical exams, including final exams, midterm exams, and national board exams, when exposed to TBL compared to lecture [12, 16, 19, 25–33]. Moreover, when compared with pre-test assessments, TBL consistently demonstrated improved cognitive outcomes [17, 34–36].

Retention

Among the 23 reviews analyzed, four reviews (17.39%) specifically reported on the long-term retention of knowledge in TBL. The results of these studies were mixed. Two out of the four reviews (50%) reported no significant difference or advantage in long-term retention of knowledge [19, 28]. One review out of the four (25%) reported mixed results, with some primary studies indicating no difference in long-term retention while others reported comparable results [36]. Additionally, one review out of the four (25%) reported that knowledge obtained through TBL was retained for several months, suggesting a positive impact on long-term retention [32].

A-2: Cognitive Outcomes Compared with Other Active learning Methods.

Based on the reviews analyzed, it appears that there is insufficient evidence to draw a robust conclusion regarding the comparison of TBL with other active learning methods. Three out of the 23 reviews (13%) specifically mentioned this comparison in their results. In the first review, TBL was compared with Case-Based Learning (defined as A student-centered approach where a real case/scenario is presented to engage students in application of knowledge )The findings indicated no significant differences in examination scores between these methods [35]. However, the review concluded that the available evidence was insufficient to draw a definitive conclusion. In another review, TBL was compared with simulation-based learning, and no significant differences were found in student scores [28]. In contrast, another review compared TBL with Small Group Learning (SGL) or CBGD and reported knowledge outcomes in favor of TBL [12].

B-1: Feeling of Learning Compared with Lecture.

Satisfaction

In the literature on TBL, satisfaction has been one of the most extensively studied areas. Among the 23 reviews analyzed, 9 reviews (39.13%) specifically addressed satisfaction as an outcome of TBL, either in comparison with lecture or without any specific comparison. Out of these 9 reviews, 7 (77.77%) consistently reported higher levels of satisfaction [19, 28, 29, 33, 34, 36, 37]. However, it is important to note that 2 reviews (22.22%) reported mixed results in terms of satisfaction. These reviews indicated that while some students expressed positive reactions towards TBL, there were also negative reactions due to perceived higher workloads or challenges associated with the TBL method [12, 17].

Attitude

Three reviews (13%) specifically reported on students’ attitudes towards TBL. All consistently found that students had a positive attitude towards TBL when compared to lecture [25, 35, 36].

Preference of TBL

Among the 23 reviews analyzed, three reviews (13%) specifically reported on student preferences for TBL compared to lecture. The results were mixed. Two of the reviews indicated that learners preferred TBL over traditional forms of instruction, particularly lecture [19, 32]. However, one review reported that students did not prefer TBL over lectures [28].

Motivation

One review (4.34%) specifically emphasized that TBL fostered enthusiasm for learning when compared to lecture [26]. Additionally, one review, which included self-report data, reported that TBL increased students’ motivation for learning. It further indicated that students allocated more time to engage in learning activities when exposed to TBL [16].

B-2: Feeling of Learning Compared with Other Active learning Methods.

Satisfaction

One review (4.34%) specifically compared learners’ satisfaction between TBL and another active learning method. In this particular review, it was reported that learners expressed higher satisfaction with case-based learning compared to TBL. This finding suggests that learners preferred case-based learning over TBL in terms of satisfaction.

Attitude, preference of TBL and motivation

There is currently a lack of reviews specifically examining and comparing motivation for learning, preference of TBL and attitude of students with other active learning approaches. This indicates that the research in these particular areas of TBL is not well-developed or extensive.

C-1: Performance and skills.

Four out of the 23 reviews (17.39%) included performance scores in their results. All four reviews consistently reported higher clinical performance skills [28], skill scores [30], practice ability [31], and transfer of learning in real-world work environments [17] in favor of TBL.

D: Learners’ engagement.

Engagement as an outcome

Learners’ engagement as an outcome of TBL was reported in 30.43% (7 out of 23) of the reviews. Among these, 71.42% (5 out of 7) reported higher engagement in TBL compared with lecture [19, 28, 29, 36, 37]. In 28.57% (2 out of 7) of the reviews, high engagement in TBL sessions was reported but without a comparator [16, 33]. One review concluded that there is evidence that TBL promotes engagement, regardless of the achievement of learning outcomes [12]. Furthermore, one study reported higher engagement of instructors as well as learners in TBL sessions [36].

Pattern of engagement

Out of the 23 reviews analyzed, only one study (4.34%) examined the patterns of engagement in TBL. This particular review identified three types of engagement in TBL: learner-to-learner, learner-to-facilitator, and learner-to-self/content (i.e. pre-reading). Among these types, learner-to-learner engagement was found to be the most prevalent in TBL sessions [19].

E: Non-Technical Skills.

Team work

Four out of the 23 reviews (17.39%) examined team work as an outcome of TBL. Among these, two reviews (50%) reported mixed results, indicating both positive and negative effects of TBL on students’ attitudes toward team work [17, 29]. One review out of the four reported a positive effect of TBL on students’ perception of the value of team work [36], while another study highlighted that TBL facilitates teamwork [37]. Considine concluded that more research is needed to expand beyond student attitudes and perceptions and focus on objective measures of teamwork and team performance in TBL [29].

Thinking ability

Among the 23 reviews analyzed, a total of five reviews (21.73%) investigated the effects of TBL on various thinking abilities. Notably, two of these reviews [28, 38]. presented conflicting findings regarding the development of critical thinking skills. Specifically, one study [37] reported that TBL facilitates critical reasoning, while another study [26] found that TBL improves overall thinking ability compared to lecture. Furthermore, one study [33] observed that TBL enhances the ability to integrate knowledge into critical thinking. These findings collectively suggest that TBL can have a positive impact on various dimensions of thinking abilities.

Communication skills

A total of three out of the 23 reviews (13%) included in the analysis reported a notable improvement in communication skills associated with the implementation of TBL. These reviews collectively indicated that TBL had a positive impact on enhancing communication abilities [16, 26, 28].

Problem solving

Among the 23 reviews analyzed, three reviews (13%) specifically investigated the impact of TBL on problem-solving abilities. Only one review unequivocally confirmed the effectiveness of TBL in enhancing problem-solving skills [33]. In contrast, the remaining two reviews yielded mixed results [28, 38]. However, it is noteworthy that despite the mixed outcomes, these two reviews highlighted that over 50% of the primary studies supported TBL as an approach to improve problem solving.

Decision making

Among the reviewed studies, a solitary review focused on the impact of TBL on clinical decision-making in undergraduate clinical disciplines. This specific review reported an improvement in clinical decision-making skills as an outcome of TBL implementation [36].

Self-study and learning ability

Out of the 23 reviews examined, two reviews (8.70%) provided favorable results supporting the effectiveness of TBL to promote learning and study skills. One of these reviews was a meta-analysis, which reported a significant improvement in learning skills in Chinese students [25]. The other study confirmed that TBL has a substantial impact on self-study ability when compared to traditional lecture [26].

Emotional intelligence

Among the 23 reviews analyzed, only one review specifically examined the impact of TBL on emotional intelligence. The results of this review confirmed that TBL has a positive effect on various sub-concepts of emotional intelligence, including the awareness of emotions of self and others, as well as the management of emotions [36].

F: Educators in TBL literature.

Faculty workload

A consistent pattern observed across the four reviews (17.39%) that examined faculty workload in the context of TBL is an initial increase in workload. Out of these four reviews, three reported an increase in workload in the beginning [17, 19, 34]. However, these reviews also highlighted that with experience and familiarity, faculty members were able to optimize their workload related to TBL. One study reported that TBL required more time (12 h versus 5 h) compared to lecture [36]. On the other hand, the other study emphasized that the gains obtained from TBL were a result of the efforts and time allocation invested in the approach [19].

Attitude of educators

Among the reviewed studies, three studies (13%) specifically reported positive attitudes towards TBL among educators. The consistent pattern observed across these studies suggests that educators generally appreciate the atmosphere created in TBL classes, which fosters increased engagement and enjoyment [34, 36]. However, it is important to note that one study by Reimschisel et al. (2017) mentioned facilitators having a positive attitude towards TBL without specifying whether they were senior students or educators [19].

Faculty development

Only one review mentioned the issue of facilitator or educator training in TBL prior to implementing the method. This particular review reported that the training provided to facilitators was minimal, often limited to reading about the TBL method or attending a one-day workshop. The findings suggest that in many cases, the training received by facilitators was limited in duration and scope [19].

G: TBL class attendance.

Out of the 23 reviews analyzed, three reviews (13%) specifically focused on learner attendance in the TBL classes. Collectively, these reviews consistently reported higher learner participation and attendance rates in TBL [17, 19, 29]. One review compared attendance in TBL with lecture classes and found higher attendance in TBL [29]. However, the other two reviews did not provide a comparative for attendance. Notably, Reimschisel emphasized that it was unclear from the primary studies whether attendance was mandatory in TBL or not [19].

H: Barriers of TBL.

Three reviews (13%) identified barriers or negative perspectives towards TBL. One review found TBL to be inferior to case-based learning due to its perceived rigidity [35]. Another review highlighted challenges in adapting to TBL, including time-consuming pre-class preparation and concerns about assessment scores [30]. A third review expressed initial dissatisfaction with TBL implementation [29].

RQ3: what groups have benefited the most from TBL?

Age

Among the 23 reviews analyzed, only one meta-analysis reported that freshman students derived greater benefits from TBL in terms of theoretical scores. However, no statistically significant difference was observed in skill scores between freshman students and other student groups [30].

Academically weaker students

Six reviews (26.08%) specifically reported that academically weaker students benefited more from TBL compared to students at the higher end of the class. These findings suggest that TBL can be particularly advantageous for students who may struggle academically or have lower initial proficiency levels. However, it is important to note that all students, regardless of their initial academic standing, benefitted from TBL [17, 19, 28–30, 37].

Level of education

Among the reviewed studies, three reports (13%) specifically examined the impact of TBL based on the level of education. The findings consistently indicated that undergraduate students [25], particularly those in higher years of education, benefited more from TBL [26]. Furthermore, the effectiveness of TBL was reported to increase as the level of education progressed. However, when it came to first-year nursing students, the results were mixed, suggesting that the impact of TBL on this particular group may vary [28].

Gender

According to a single metanalysis, female students in a TBL course experienced a greater increase in examination scores compared to male students in China [25].

Discipline

According to two reviews, nursing students demonstrated higher grades in TBL compared to non-nursing students. Additionally, nursing students exhibited higher levels of satisfaction, engagement, and a more positive attitude towards TBL compared to students in other HPE fields [33, 39].

RQ4: what are the most and least researched TBL elements in reviews and what are the under-studied areas?

Students preparation

Among the reviews analyzed, two reviews (8.69%) highlighted negative aspects of the pre-class phase in TBL. One review mentioned that learners’ preparation was time-consuming [30], while another review reported that the out-of-class preparation received unfavorable comments [32]. On the other hand, two reviews discussed the pre-class learning methods used in TBL. One review reported the use of various technologies, such as live webinars, multimedia resources, and online quizzes, to facilitate pre-class learning in TBL [40]. The other review mentioned that students preferred narrated slides or recorded lectures [19].

Team formation and size

Team formation and size were the most frequently studied elements in TBL. Five out of the 23 reviews (21.73%) specifically reported on team size and the team formation process in TBL. In three of these reviews, various team numbers were reported. One review found that the number of team members ranged from 4 to 12 [41]. Another review reported that more than 50% of the primary articles indicated team sizes of 5 to 7 members, with some variations ranging from 2 to 3 members up to 7 to 10 members per team [42]. In a third review, team sizes were reported to range from 4 to 6 to 9 to 10 members, with the most common team size being 6 to 8 members [43]. Additionally, a meta-analysis indicated that team size acted as a mediator of content knowledge outcomes, with smaller group sizes leading to better content knowledge outcomes [27].

Regarding team formation methods, three reviews out of the five reported random or semi-random allocation as the dominant method [29, 41, 43]. Gender and experience were sometimes used to ensure heterogeneity within teams [41]. However, one review noted that team formation based on gender could be a cultural issue, and in some non-Western countries, it had a negative impact on forming cohesive teams [19].

RAT tools

Among the reviews analyzed, three reviews (13%) reported on the RAT tools or types of questions used in TBL. Two of the reviews (out of three) indicated that Multiple Choice Questions (MCQs) were the dominant type of questions used in the RAT process [29, 43]. In one review, conducted by Considine, the range of RAT items varied from 4 to 40 questions. Another review, conducted by Burgess, reported a range of 3 to 21 questions used in the RAT. Additionally, two reviews mentioned that a combination of paper-based, online, and scratch card formats was utilized in the RAT process within the TBL [40, 43].

Application Ex

Among the 23 reviews analyzed, two reviews (8.69%) specifically reported on the Application Exercise phase in TBL. One review highlighted the importance of the “4S” element in TBL but noted that it was the least reported aspect [29]. The format of the Application Exercise was predominantly cases or scenarios, and the type varied from paper-based to electronic formats [29]. In another review, the use of technology in the Application Exercise phase was discussed. The audience response system and iPads were reported as tools used in this phase [40]. However, the results of incorporating technology in TBL were mixed. Some studies found no significant difference in students’ learning outcomes and satisfaction, while others reported positive outcomes [40].

Peer evaluation

Among the reviews analyzed, only one review specifically examined the aspect of peer evaluation in TBL. The review, conducted by Reimschisel, reported unfavorable results regarding peer evaluation in TBL. According to the review, students and faculty were critical of this aspect, noting that it was not successful due to issues such as incomplete forms or team members receiving the same ratings [19]. Peer evaluation was the least researched element of TBL.

Under-studied areas

Among the 23 reviews analyzed, six reviews (26.09%) highlighted under-studied areas within the TBL literature. These areas include the pattern of engagement and methods of team selection, which one review identified as requiring further investigation [19]. Another review emphasized the need for more research into refining exercises to develop non-technical skills [34]. Furthermore, one study highlighted the importance of exploring educators’ attitudes and experiences with TBL [17]. Understanding which specific characteristics of TBL are highly appreciated by educators could provide valuable insights [30]. Another review focused on the long-term effects of TBL, suggesting that more studies are needed to examine the lasting impact of TBL on learners [12].

Discussion

Over the past decade, there has been a notable increase in the number of reviews focusing on TBL. However, this particular work stands out as the first umbrella review specifically addressing TBL in HPE. This study was conducted to identify gaps and summarize the results of systematic and scoping reviews related to TBL.

The findings of this study shed light on the increasing utilization and recognition of TBL as a pedagogical approach in medical education. The annual publication rate of at least two reviews attests to the growing popularity and acceptance of TBL among HPE educators and institutions. However, a critical analysis of the literature indicates an evident lack of balance in terms of geographic distribution and inclusion of diverse academic disciplines. The observed dearth of studies from certain regions and the underrepresentation of specific majors raises important considerations regarding the generalizability and applicability of TBL across different contexts. The limited geographical diversity implies potential gaps in understanding the cultural, societal, and educational nuances that may impact the implementation and effectiveness of TBL. Similarly, the limited inclusion of diverse academic disciplines suggests a potential bias in the current body of literature, which may limit the comprehensive examination of TBL’s impact on medical education as a whole. The implications of the study underscore the necessity for expanded initiatives aimed at introducing and promoting the adoption of the TBL method in diverse countries, particularly within African and European nations. The identified imbalance in geographical representation highlights the potential benefits of bridging this gap by implementing TBL in regions where its utilization may be limited or underexplored. By doing so, educators and institutions in these areas can leverage the advantages of TBL and enhance the quality of medical education. Furthermore, the study highlights the importance of extending TBL research efforts beyond clinical fields and into basic science or non-clinical disciplines. While TBL has gained significant traction within clinical settings, its application and potential impact in non-clinical domains remain relatively unexplored. Investigating the implementation of TBL in basic science education can provide valuable insights into its effectiveness in fostering critical thinking, problem-solving, and collaborative skills among students pursuing scientific disciplines. The findings of the study revealed a noteworthy trend indicating that more than two thirds of the identified reviews on TBL were published in journals categorized as Q1, which signifies their high prestige and impact within the field of HPE. This observation underscores the recognition and significance attributed to TBL by esteemed scholars and prestigious journals in the HPE community.

The results provide insights into the cognitive outcomes and retention of knowledge associated with TBL compared to Lecture. In the short term, the cognitive outcomes of TBL were extensively studied, with a majority of the reviewed literature supporting the superiority of TBL in enhancing students’ cognitive performance. The findings consistently demonstrated that students performed better in theoretical exams when exposed to TBL compared to lecture. This includes performance in final exams, midterm exams, and national board exams.

However, when examining the long-term retention of knowledge in TBL, the results were more varied. Overall, these results underscore the effectiveness of TBL in improving students’ cognitive outcomes in the short term, as evidenced by superior performance in theoretical exams compared to lecture. However, the impact of TBL on long-term retention appears to be less conclusive, with mixed findings reported across the reviewed literature. Further research is needed to better understand the factors influencing long-term retention in TBL and to identify strategies for optimizing retention in this instructional method. The results can be understood and interpreted through the lens of cognitive load theory. Cognitive load theory posits that learning is influenced by the cognitive load imposed on learners’ working memory [44].

In the short term, TBL demonstrated superior cognitive outcomes compared to lecture-based instruction. This finding aligns with cognitive load theory, as TBL typically engages students in active learning and problem-solving. These activities distribute the cognitive load across different cognitive processes, such as information processing, decision-making, and reflection. By actively participating in team discussions and problem-solving tasks, students are more likely to engage in deep processing and elaboration of information, leading to improved understanding, retention, and application of knowledge. On the other hand, the mixed findings regarding long-term retention in TBL could be attributed to various factors. Cognitive load theory suggests that effective learning requires appropriate cognitive load management [45]. In TBL, the collaborative activities, group discussions, and problem-solving tasks may initially result in a higher cognitive load, facilitating short-term learning gains. However, the long-term retention of knowledge depends on the transfer of learned information from working memory to long-term memory through processes such as encoding and consolidation. If the cognitive load during the learning process exceeds the capacity of working memory, it may impede the encoding and consolidation of knowledge, leading to reduced long-term retention [44].

The results indicate that there is insufficient evidence to draw a robust conclusion regarding the comparison of cognitive outcomes in TBL with other active learning methods i.e. flipped classroom. Only three reviews specifically addressed this comparison in their results, highlighting the limited research available in this area. These findings suggest that more research is needed to establish a clear understanding of the comparative effectiveness of TBL in relation to other active learning methods. The limited evidence available in the reviewed studies does not allow for definitive conclusions to be drawn regarding the superiority or inferiority of TBL compared to alternative approaches. The available literature on comparing active methods with TBL is limited, and there is a lack of information regarding their cost effectiveness. It is important to explore and evaluate active methods that require fewer resources to determine if they can yield similar results. This knowledge can inform decision-making when incorporating active methods into the curriculum, especially in settings with limited resources. Additionally, it is crucial to investigate the outcomes beyond cognitive knowledge that active methods can generate. Understanding which active methods have a profound and lasting impact, as well as identifying any potential drawbacks or inefficiencies, is necessary. This knowledge can guide educators in selecting the most effective and efficient active methods to promote comprehensive learning outcomes. However, the comparison results to other active learning strategies might be a bit muddled since the other strategies are not well-defined and lack fidelity to a method that has no structural definition like TBL.

The term “feeling of learning” refers to students’ perceptions of the method’s effectiveness and their internal experiences related to TBL [46]. This includes factors such as satisfaction, attitude, motivation, and reactions that students report in relation to their TBL learning experiences. Understanding and assessing students’ feelings of learning can provide valuable insights into the impact and effectiveness of TBL. The results indicate that TBL is associated with higher levels of satisfaction, positive attitudes, and increased motivation for learning when compared to lecture in many instances. However, there are also mixed findings and variations in student preferences for TBL. Satisfaction was extensively studied in the literature, with the majority of the reviewed literature consistently reporting higher levels of satisfaction among students engaged in TBL. Some students expressed positive reactions, while others had concerns related to perceived higher workloads or challenges associated with the TBL method. Similarly, students consistently demonstrated a positive attitude towards TBL when compared to lecture. Regarding student preferences, the results were mixed. These differing preferences may be influenced by various factors, such as learning preferences and prior experiences. In terms of motivation, one review highlighted that TBL fostered enthusiasm for learning compared to lecture. relying solely on students’ perceptions of learning can inadvertently promote passive instructional methods. For example, if students have a highly positive feeling of learning in lectures, they may prefer those over active learning approaches. It is important to consider that when students experience the cognitive effort associated with TBL, they may initially interpret it as a sign of poorer learning. This disconnection between perceived effort and learning outcomes can have negative effects on students [46].

The results indicate that there is limited research comparing learners’ feeling of learning between TBL and other active learning methods. Regarding satisfaction, only one review directly compared learners’ satisfaction between TBL and another active learning method. In this particular review, learners expressed higher satisfaction with case-based learning compared to TBL. This finding suggests that learners preferred case-based learning over TBL in terms of satisfaction. However, it is important to note that this result is based on a single review, and more studies are necessary to validate and extend this finding to other active learning methods. In terms of attitude, preference, and motivation for learning, this umbrella review identified a lack of reviews specifically examining and comparing these factors between TBL and other active learning methods. This scarcity of research findings may be attributed to several factors; Firstly, TBL as an instructional approach is relatively new in HPE, and its adoption in various educational contexts may still be evolving Secondly, the prevalence of lecture in HPE may further contribute to the scarcity of research on alternative active learning approaches. Traditional lecture formats have been dominant in many HPE settings, which could limit the exploration and implementation of other active learning methods [47].To fill these gaps, future studies should aim to compare TBL with various active learning methods. Such studies can provide valuable insights into the strengths and weaknesses of different active learning instructions and help educators make informed decisions regarding instructional design and implementation.

Our findings suggest that TBL is associated with improved performance scores in various domains. These reviews reported higher scores in clinical performance skills, skill acquisition, practice ability, and transfer of learning in real-world work environments when comparing TBL to other instructional methods. TBL places a strong emphasis on the application phase (TAP phase) [48]. After acquiring foundational knowledge individually, learners come together in teams to apply that knowledge to solve complex problems or cases.

The results highlight the significance of learners’ engagement as an outcome of TBL. The majority of the reviewed studies reported higher engagement in TBL compared to lecture, while one study focused on the patterns of engagement and identified learner-to-learner interaction as the most prevalent form. These findings align with the social constructivist learning theory, which emphasizes the importance of social interactions and collaborative learning in promoting engagement. TBL’s emphasis on peer-to-peer engagement supports the creation of an active and participatory learning environment, fostering higher levels of engagement among learners.

We examined the outcomes of TBL on non-technical skills, including teamwork, thinking ability, communication skills, problem-solving, decision-making, self-study and learning ability, and emotional intelligence. The findings provide insights into the effects of TBL on these skill domains. The results demonstrates that TBL can have positive effects on various non-technical skills, including teamwork, thinking ability, communication skills, problem-solving, decision-making, self-study and learning ability, and emotional intelligence. According to the social cognitive theory, learning occurs through the reciprocal interaction between personal factors, behavior, and the environment. TBL provides an environment that promotes active engagement, collaboration, and social interaction, which can positively influence the development of non-technical skills [49]. The reviews included in the analysis were limited in their focus on non-technical skills. Moreover, other important non-technical skills, such as leadership and creativity were not explicitly addressed in the reviewed studies. Future research should explore the impact of TBL on a broader range of non-technical skills.

The results of the umbrella review shed light on three key domains related to educators in the context of TBL: faculty workload, attitude of educators, and faculty development. These findings provide insights into how educators perceive and experience TBL, highlighting both challenges and positive aspects. The reviewed studies consistently indicated an initial increase in faculty workload when implementing TBL. This increase in workload was reported in three out of the four reviews examined. However, it is crucial to note that these reviews also emphasized that with experience and familiarity, faculty members were able to optimize their workload related to TBL. This suggests that while TBL may require additional effort and time initially, educators can streamline their approach and find efficiencies over time. The results highlighted positive attitudes among educators towards TBL. Three studies specifically reported positive attitudes towards TBL among educators. The consistent pattern observed across these studies suggests that educators generally appreciate the atmosphere created in TBL classes, which fosters increased engagement and enjoyment.

The findings indicate that there is limited emphasis on facilitator or educator training in TBL prior to its implementation. Only one review addressed this issue, reporting that the training provided to facilitators was often minimal and brief. Facilitators typically received training in the form of reading about the TBL method or attending a one-day workshop. This suggests that in many cases, the training received by facilitators lacks depth and duration. Insufficient training may pose challenges for educators in effectively implementing TBL and maximizing its benefits [48]. Adequate and comprehensive training programs for facilitators could enhance their understanding of TBL principles, strategies, and best practices, thus improving the overall implementation of TBL. The Community of Inquiry (CoI) framework suggests that meaningful learning occurs through the intersection of three presences: social presence, cognitive presence, and teaching presence [50]. In the context of TBL, faculty workload and attitude of educators can be understood within the social presence and teaching presence domains. The initial increase in workload may be attributed to the efforts required to establish a collaborative and engaging social presence in TBL classes. However, as educators become more familiar with TBL, they can optimize their teaching presence, finding efficiencies to balance workload and enhance student learning outcomes. The positive attitudes observed among educators align with the notion of social presence, indicating that TBL creates an environment that fosters positive interactions, engagement, and enjoyment. Furthermore, the limited emphasis on faculty development in TBL aligns with the need for enhanced teaching presence. Providing comprehensive and in-depth training to educators can strengthen their teaching presence in TBL classrooms, enabling them to effectively implement the approach and utilize its pedagogical principles. A more robust faculty development program could include training sessions, workshops, mentoring, and ongoing support, empowering educators to navigate the challenges and capitalize on the benefits of TBL.

The umbrella review examined the topic of learner attendance in the TBL classes. The results consistently indicated higher learner participation and attendance rates in TBL compared to other instructional formats. One review directly compared attendance in TBL with traditional lecture classes and found that TBL classes had higher attendance rates. This suggests that TBL may be more effective in motivating and engaging students, leading to increased attendance, we know attendance can have several benefits, including improved opportunities for collaborative learning, enhanced interaction and increased opportunities for minimizing the misunderstandings. It is important to note that the other two reviews did not provide a comparative analysis of attendance between TBL and other instructional formats. However, they still reported higher learner participation and attendance rates in TBL. The issue of mandatory attendance in TBL was highlighted in the one review. It mentioned that it was unclear from the primary studies whether attendance was mandatory in TBL or not. This raises an interesting point regarding the influence of mandatory attendance policies on attendance rates in TBL. While the umbrella review did not provide a definitive answer on this matter, it implies that the higher attendance rates observed in TBL may be due to a combination of factors, including the collaborative nature of the approach, increased student engagement, and the potential influence of attendance policies.

One review compared TBL with case-based learning and reported a negative perspective towards TBL, considering it inferior to case-based learning. The perceived rigidity of TBL was cited as the primary reason for this assessment. This finding suggests that some educators or researchers may prefer other instructional approaches over TBL due to concerns about the flexibility and adaptability of TBL in meeting specific learning objectives or addressing complex case scenarios. Another review highlighted several challenges faced during the adaptation of TBL. These challenges included time-consuming pre-class preparation and concerns about assessment scores. Additionally, concerns about assessment scores may arise when educators consider the impact of TBL on traditional grading systems or worry about the comparability of assessment outcomes between TBL and other instructional methods. The third review expressed initial dissatisfaction with TBL implementation without providing specific reasons. While this review did not elaborate on the nature of the dissatisfaction, it indicates that there may be instances where educators or learners experience initial difficulties or reservations when adopting TBL. The perception that TBL is inferior to case-based learning may stem from the perceived relative advantage of case-based learning in certain contexts or for specific learning goals. The rigidity of TBL, as perceived by some, may suggest a lack of compatibility with existing instructional practices or preferences. The challenges associated with time-consuming pre-class preparation and concerns about assessment scores reflect the complexity of implementing TBL. It is essential to acknowledge that negative perspectives or barriers identified in these reviews represent a minority of the analyzed studies.

The umbrella review aimed to identify the groups that have benefited the most from TBL. Several factors were examined, including age, level of education, gender, and discipline, to understand their influence on the benefits derived from TBL.

Among the analyzed reviews, only one meta-analysis reported that freshman students derived greater benefits from TBL in terms of theoretical scores. However, no significant difference was found in skill scores between freshman students and other student groups. This suggests that TBL may be particularly beneficial for freshman students in terms of theoretical knowledge acquisition. It is important to note that skill scores did not show a significant variation, indicating that TBL can benefit students of various ages in terms of skill development. Several reviews highlighted that academically weaker students derived greater benefits from TBL compared to students at the higher end of the class. This implies that TBL can be particularly advantageous for students who may struggle academically or have lower initial proficiency levels. However, it is important to emphasize that all students, regardless of their initial academic standing, still benefited from TBL. The findings consistently indicated that undergraduate students, particularly those in higher years of education, benefited more from TBL. The effectiveness of TBL was reported to increase as the level of education progressed. However, the impact of TBL on first-year nursing students yielded mixed results, suggesting that the benefits of TBL for this group may vary. These findings indicate that TBL may be particularly effective in promoting learning outcomes among undergraduate students, especially as they advance in their educational journey. According to a single meta-analysis, female students in a TBL course experienced a greater increase in examination scores compared to male students in China. This suggests that TBL may have a positive impact on female students’ academic performance. However, it is important to consider that this finding is based on a specific cultural context and may not be generalizable to other settings or populations. And finally, two reviews highlighted the impact of TBL in different disciplines. Nursing students consistently demonstrated higher grades in TBL compared to non-nursing students. Additionally, nursing students exhibited higher levels of satisfaction, engagement, and a more positive attitude towards TBL compared to students in other HPE fields. These findings suggest that TBL may be particularly well-suited for nursing education, promoting both academic achievement and positive attitudes towards the learning experience. In the context of TBL, personal factors such as prior academic standing, level of education, and gender, as well as environmental factors such as the discipline being studied, may influence individuals’ cognitive processes and learning outcomes. TBL’s collaborative and interactive nature may provide a conducive environment for certain groups, such as academically weaker students or undergraduate students, to engage in active learning, receive peer support, and enhance their learning outcomes.

The findings provide valuable insights into various aspects of TBL elements. The pre-class phase of TBL received mixed feedback in the reviewed literature. While some reviews mentioned negative aspects, such as time-consuming preparation or unfavorable comments on out-of-class preparation, other reviews highlighted the use of various technologies and preferred learning methods. Further research is needed to explore effective pre-class learning methods and address potential challenges in this phase. From our experience, this generation of learners grows up hating to read since all the media options are easier, though learning outcome is likely diminished, i.e. critical thinking develops from reading [51].

Team formation and size emerged as the most frequently studied element of TBL. The reviews provided insights into the range of team sizes reported in TBL. Smaller team sizes were found to be associated with better content knowledge outcomes. Random or semi-random allocation was the dominant method for team formation, with occasional consideration of gender and experience to ensure heterogeneity. However, the cultural impact of team formation based on gender was noted, indicating the need for contextual considerations. These findings suggest that team formation and size play a crucial role in TBL and should be carefully considered to optimize learning outcomes and promote team cohesion. The Readiness Assurance Test (RAT) tools or types of questions used in TBL were addressed in a subset of the reviewed literature. Multiple Choice Questions (MCQs) were identified as the dominant type of questions used in the RAT process. The range of RAT items varied across the reviews, highlighting the flexibility in question selection. Additionally, a combination of paper-based, online, and scratch card formats was utilized for RAT administration. These findings provide insights into the common practices for assessing readiness and promoting active engagement during the RAT phase of TBL. The Application Exercise phase of TBL received relatively less attention in the reviewed literature. However, two reviews highlighted its importance and discussed the format and use of technology in this phase. The Application Exercise predominantly involved cases or scenarios, with variations in formats such as paper-based or electronic. The incorporation of technology, such as audience response systems and iPads, yielded mixed results in terms of learning outcomes and satisfaction. These findings suggest that further exploration of effective application exercise designs and technology integration is warranted to enhance the effectiveness of this phase. Peer evaluation emerged as the least researched element of TBL, with only one review specifically examining this aspect. The findings from that review indicated unfavorable results regarding peer evaluation in TBL. Issues such as incomplete forms and team members receiving the same ratings were reported as challenges. The limited research on peer evaluation in TBL suggests a gap in understanding its implementation and potential benefits or drawbacks. Further investigation is needed to explore effective strategies for peer evaluation and address the identified challenges.

The identified under-studied areas within the TBL literature provide valuable directions for future research and highlight gaps in our current understanding of TBL. These areas encompass the pattern of engagement and methods of team selection, the refinement of exercises for developing non-technical skills, educators’ attitudes and experiences with TBL, and the long-term effects of TBL on learners. One review identified the pattern of engagement and methods of team selection as areas requiring further investigation. Understanding the patterns of engagement and refining team selection methods can potentially enhance collaboration and the overall effectiveness of TBL. The need for more research into refining exercises to develop non-technical skills was emphasized in one review. TBL is known for its focus on promoting not only content knowledge but also teamwork, communication, critical thinking, and problem-solving skills. Investigating and refining exercises that effectively target the development of these non-technical skills could contribute to further optimizing TBL outcomes. Understanding educators’ attitudes and experiences with TBL was highlighted as an important area of investigation. One review emphasized the need for more studies investigating the long-term effects of TBL. Exploring educators’ perspectives can help identify barriers, challenges, and facilitators of TBL implementation, as well as effective instructional strategies that enhance its efficacy.

Conclusion and recommendations

This is the first umbrella review specifically addressing TBL in HPE. The comprehensive analysis of TBL research spanning from 2013 to 2024 reveals several important insights. First, TBL consistently enhances students’ cognitive performance, positioning it as a valuable pedagogical approach. However, the evidence regarding retention remains inconclusive, emphasizing the need for further investigation. Second, the geographical distribution of TBL studies highlights the dominance of the United States and China, indicating the global interest in this teaching method. Moreover, the majority of primary studies focused on students from clinical fields such as medicine, nursing, pharmacy, and dentistry. Educators in these disciplines can leverage TBL to foster active learning and improve student outcomes. Third, students exhibit positive attitudes and satisfaction toward TBL when compared to traditional lecture-based instruction. This finding underscores the importance of creating engaging and collaborative learning environments. Educators should consider incorporating TBL into their teaching repertoire to enhance student motivation and satisfaction. Fourth, preferences for TBL vary across studies, suggesting that instructors should tailor their instructional strategies based on student needs and context. While some learners thrive in team-based settings, others may prefer alternative approaches. Flexibility in instructional design is crucial. Fifth, TBL demonstrates favorable outcomes in terms of clinical performance skills and student engagement. Educators can capitalize on TBL’s ability to promote active participation, critical thinking, and problem-solving skills. By integrating TBL into curricula, educators can better prepare students for real-world challenges. Recognizing that TBL may not be universally preferred by all students, be open to adjusting their teaching methods based on student feedback. Invest time in faculty development programs to equip educators with the necessary skills for implementing TBL is necessary. Address concerns related to workload and duration is a key. further research should be encouraged on TBL, especially in areas with mixed results (e.g., retention and non-technical skills).

Limitations

In conducting this umbrella review, several limitations were identified. Firstly, the review exclusively included articles published in English, potentially overlooking relevant studies in other languages. Secondly, gray literature was not searched, which may have led to the exclusion of valuable unpublished studies or reports. Thirdly, only systematic and scoping reviews were considered, which might have limited the breadth of the evidence base. Additionally, some of the included reviews focused solely on Chinese students, introducing a potential bias due to the lack of diversity in the study populations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

Authors MA and AN contributed with the study’s conceptualization, methodology, screening, assessment of methodological quality, data extraction, data summary, supervision and writing of the initial manuscript. RM contributed to the writing of the search strategy, literature search and assessment of methodological quality sections. MKM contributed to the data summary, and DP and RJkh participated in both the conceptualization and data summary sections. All authors contributed to the study and read and approved the final version of the manuscript.

Funding

This project is partially founded by the Team-Based Learning Collaborative (TBLC), teambasedlearning.org.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval

This study was approved by the Ethics Committee of Tehran University of Medical Sciences with the ethics code IR.TUMS.MEDICINE.REC.1403.134.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.