From Resistance to Engagement: Factors That Influence Student Outcomes in Team-Based Learning

From Resistance to Engagement: Factors That Influence Student Outcomes in Team-Based Learning | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Resistance to Engagement: Factors That Influence Student Outcomes in Team-Based Learning Homaira M. Azim, Yaniv N. Maddahi, Christian P. Near, Ryan Y. Lee, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6658854/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Traditional didactic methods in health sciences education are increasingly being replaced with active learning strategies such as Team-Based Learning (TBL), which fosters engagement through collaboration, knowledge application, and peer interaction. This study provides practical insights for educators aiming to integrate TBL into biomedical basic science courses, focusing on student feedback and perceptions about TBL format in one graduate-level histology course. Methods : Study participants included students from two separate offerings of the same graduate histology course (Cohort A: n = 28; Cohort B: n = 27). All students enrolled were invited to participate in the study by completing a questionnaire and/or participating in a focus group. Eleven students completed the questionnaire (5 from Cohort A; 6 from Cohort B), and 18 participated in the focus groups (7 from Cohort A; 11 from Cohort B). Qualitative data were analyzed using an abductive approach, incorporating frame and taxonomic analyses. Results: Four key themes emerged as conditions influencing students’ engagement with TBL: (1) preparation and self-regulated learning, (2) understanding and valuing teamwork, (3) student motivation, and (4) attitudes toward active learning. Conclusion: Grounded in constructivist learning theory, TBL can offer a transformative educational experience by promoting self-regulation, collaboration, and deeper engagement. However, its success depends on factors such as student readiness, team cohesion, and prior exposure to active learning, which underscores the need for deliberate instructional design, explicit student orientation, and consistent faculty facilitation to ensure effective implementation. Team-based learning biomedical education health sciences education self-regulated learning constructivist learning. Figures Figure 1 Figure 2 BACKGROUND Team-Based Learning (TBL), originally developed in the 1970s by Larry Michaelsen, has emerged as a powerful approach to promote active learning through structured small-group work under instructor guidance (Levine & Hudes, 2021). While often positioned as an alternative to traditional large-group lectures, TBL can also serve as a valuable supplement to lectures, enhancing student engagement and understanding. The traditional TBL format requires pre-class student preparation, an individual readiness assurance test (iRAT), a group readiness assurance test (gRAT), and concludes with whole-class discussion and instructor feedback. This structure effectively shifts the instructor’s role from content deliverer to learning facilitator (Koles et al., 2010; Michaelsen & Sweet, 2004; Silva et al., 2021). To fully realize the benefits of this instructional approach, creating a supportive learning environment is critical, as the potential of TBL to deepen content comprehension and improve academic outcomes depends on student participation and active engagement (Burgess, 2020; Hawi, 2017). The inclusion of formative assessment components, such as the iRAT and gRAT, further supports this engagement by encouraging accountability and collaboration throughout the learning process (Jabbar et al., 2018). In medical education, there has been a shift towards TBL integration within many institutions, with utilization across multiple medical subjects (Burgess et al., 2020). More recently, other disciplines have also begun adopting aspects of the TBL format through diverse formats such as weekly modules, vocabulary assessments, and collaborative assignments, highlighting the model’s versatility and adaptability (Li et al., 2021; Park & Park, 2021; Veneri & Mongillo, 2021). Although TBL has the potential to offer wide-ranging benefits – including enhanced engagement, deeper content comprehension, and improved academic outcomes – its implementation is not without challenges. A transition from didactic lectures to educating through a TBL format often requires greater institutional support and additional resources. For example, more teaching assistants, clinician involvement, and extra time may be needed for student familiarization with the new structure (Hernández, 2021). These demands can put pressure on budgets and staffing, which can then affect the quality and consistency of TBL delivery (Burgess et al., 2020). While TBL aims to enhance engagement, not all students respond positively to the increased demand for active participation. Some common problems include procrastination, unequal participation, and interpersonal conflicts, which can lead to increased student stress and diminished learning outcomes (Watkins et al., 2018). Disproportionate student contributions and challenges in peer collaboration often result in imbalanced workloads and increased team tension (Gabelica et al., 2022). Moreover, navigating differences in personalities and levels of commitment can also detract from the learning experience (Johnson et al, 2007). This emphasizes the need for strategies that can promote more balanced participation while minimizing group conflict (Van den Bossche et al., 2006). Aside from group dynamics, the self-directed nature of TBL can also pose challenges for some students. The shift to student-centered engagement often results in initial discomfort or resistance for some (Vasanet al., 2009). Students accustomed to passive, primarily lecture-based learning environments may struggle with the greater responsibility required of them in an active learning setting. For those unfamiliar with the TBL model, the expectation to engage actively and meaningfully in a small group can be overwhelming, particularly during first exposure to the format (Thomas, Mitchell, & Joseph, 2002; Haberyan, 2007). To address some of these concerns, educators have adopted various strategies to foster a more supportive and productive TBL environment. Structured team-building exercises and routine peer evaluations have been found to be effective in promoting communication and collaboration among students (Michaelsen et al., 2004; Searby & Ewers, 1997). Providing clear guidelines on team roles and expectations can also help reduce conflict and promote more equitable student participation (Johnson et al., 2007; Oakley et al., 2004). Additionally, formative assessments, i.e., the iRAT and gRAT, allow instructors to monitor individual student progress and provide them with timely feedback (Michaelsen et al., 2004). As mentioned before, a well-organized and supportive environment is crucial for fully realizing TBL’s potential to enhance learning outcomes (Van den Bossche et al., 2006). To further mitigate resistance to active learning, the literature suggests offering continuous encouragement through instructor feedback sessions, regular check-ins with teams and individual students, and maintaining open channels for students to be able to express any concerns (Haidet et al., 2012). Peer mentoring and testimonials from students who previously succeeded in TBL settings have also shown promise in easing student anxieties and leading to greater participation (Clark et al., 2008). Despite the strategies proposed in literature, challenges with student engagement and resistance in TBL environments persist. Building on the existing solutions, this study aimed to explore, in more depth, how students experience participation in TBL sessions. Specifically, we sought to understand where and why resistance may arise and the underlying reasons for student disengagement and suboptimal academic outcomes. Using a qualitative approach, this study captured the nuanced perspectives of students as they navigated the demands of a graduate-level histology course that used the TBL format. The findings of this study offer valuable implications for instructional design and student support to create more meaningful and successful learning experiences for all students in health sciences education. METHODS Conceptual Framework This study is grounded in two levels of theory (Anfara & Merz, 2015). At the grand conceptual level, it draws on critical constructivist theory (Piaget, 1971; Goodman, 2014; Kincheloe, 2005), which determined our research focus, philosophical paradigm (constructionism), formulation of the research question, and the overall methodological approach. At the micro level, additional theoretical and analytical concepts that were used to interpret the data include the Freirian concepts of banking education and problem-posing education (Freire, 2000), intrinsic motivation (Dweck, 1986; Kolencik, 2014) and self-regulated learning (Zimmerman, 2000; Bonner & Kovach, 1996). Study setting and participants This study involved two student cohorts (Cohort A and Cohort B) who were enrolled in the same graduate-level histology course at different times. This was a required course within the Master of Medical Sciences program at one medical school. Most students enrolled in the program were aspiring medical students planning to apply to medical school the following year. A total of 55 students were enrolled across the two cohorts (n = 28 in Cohort A, and n = 27 in Cohort B). Each cohort was taught by a different team of faculty instructors; however, the course content, TBL format, and curriculum were the same. The data collection instruments, including the questionnaire and focus group protocol, were also identical across both cohorts. TBL sessions were conducted once a week during the semester course for a total of 10 sessions. During each session, students took the iRAT and then gRAT quizzes (10 multiple-choice questions per quiz) at the beginning of each session (~ 25 minutes) and worked on the application exercise for the rest of time (~ 2 hours). Application exercises had two components:1) Team discussion (1 hour), during which each student team worked through the 8 clinical case-scenario questions provided in the application exercise, 2) Faculty debriefing session (~ 1 hour), which involved a whole-class discussion of the correct and incorrect answers facilitated by course faculty. Assessments conducted during the TBL sessions accounted for 30% of the final course grade, divided as follows: iRAT 10%, gRAT 5%, and application exercises 15%. The entire application exercise session was held in a testing environment, where students were not allowed to connect to the internet, use their cell phones, or leave the room. The only resources allowed were the course textbook, a medical dictionary, and a copy of Merck’s Manual, all of which were provided as hard copies at each discussion table. Students were randomly grouped into four teams (6–7 students) on the first day of the class and worked with the same team throughout the semester. The performance of the teams during each session was recorded based on the number of correct answers during the application exercises. At the end of each session, the top performing teams were recognized. However, this determination was used only to promote teamwork and engagement with the TBL format and did not contribute to the students’ final course grade. Data Generation Data collection methods used in this study included qualitative questionnaires and focus group interviews The questionnaire was designed with the goal of identifying basic overarching themes to inform the focus group protocol. All students enrolled in the course (n = 28 in Cohort A, and n = 27 in Cohort B) were invited to complete the questionnaire form, which was shared via the course Canvas (learning management system). The 7 open-ended questions (drafted by HA) asked about students’ perceptions and experiences with the TBL format (see Questionnaire instrument in supplementary material). Participation was completely voluntary and anonymous, and no incentives (e.g., extra credit) were offered. 11 students completed the questionnaire (5 in Cohort A and 6 in Cohort B). Two focus groups were conducted – one with Cohort A and one with Cohort B. Each session lasted approximately one hour and was held in person. All students enrolled in the course were invited to take part in a focus group via an announcement on the course Canvas page. Following this invitation, 20 students from Cohort A and 21 from Cohort B volunteered to participate. From this pool, 18 students were selected – 7 from Cohort A and 11 from Cohort B – using purposive sampling to ensure diverse representation in terms of age, gender, race/ethnicity, and academic performance (including students with A, B, and C grades) A free lunch was offered to all participants. Self-reported demographic data of the focus group participants are shown in Table 1 . Table 1 Demographic characteristics of students participating in both focus groups. Demographics Participants (n = 18) Age range (years) 21–28 Gender (n) Male 7 Female 11 Race/Ethnicity (n) White 6 Black 5 Latino 3 Middle Eastern 4 Focus group interviews were conducted using a semi-structured protocol consisting of 6 open-ended questions (see Focus Group protocol in the supplementary material). Sessions were audio recorded and transcribed by Zoom/Otter Live Notes ( https://otter.ai/zoom ). The initial transcripts were then checked for accuracy and corrected by members of the research team (HA for Cohort A; RL for Cohort B). Data Analysis All data were anonymized and assigned unique participant identifiers to ensure confidentiality during analysis. Participants’ ID codes used a combination of their cohort (A or B) and the data collection method – ‘Q’ for questionnaire and ‘F’ for focus group. For example, “BF4” refers to participant number 4 from Cohort B who took part in a focus group. This coding system is also used to reference data excerpts throughout the results section in this paper. The data collected through questionnaires were well-suited for frame analysis (Grbich, 2012). With 11 students responding to each of the 7 questions, the dataset was automatically segmented into 77 original response units (frames). Responses were grouped by question (Qu1 through Qu7) into seven categories, which the research team reviewed both individually and collaboratively, coding for emerging themes. The overarching themes identified through this frame analysis were then used to develop a set of taxonomies, which served as an analytical matrix for examining the focus group data through a taxonomic analysis (Grbich, 2012). An abductive, hybrid coding plan, combining inductive (data-driven) and deductive (theory-driven) approaches, guided the analysis. This method enabled the integration of theoretical constructs from the study’s critical constructivist framework while remaining open to emergent themes and subthemes within the data. To enhance the credibility and transferability of our findings, we incorporated the following methodological strategies: Triangulation and Cross-Case Analysis: Multiple forms of triangulation were employed to strengthen the credibility and analytical rigor of the study. Method triangulation involved collecting data through two distinct approaches – anonymous questionnaires and focus group interviews – from the same population. Theory triangulation was achieved during data interpretation by applying diverse theoretical and conceptual lenses, including critical constructivism, Freirean pedagogy, intrinsic motivation, and self-regulated learning theory. Analyst triangulation and cross-case analysis were incorporated by analyzing data from each cohort separately, allowing for within- and across-group comparisons. For Cohort A, initial coding was performed independently by HA and then reviewed and enhanced by DB and SH, who provided feedback and suggested refinements. For Cohort B, HA, YM, and HM each conducted independent analyses before reconciling their individual findings. The final analysis for both cohorts was reviewed by DB and HA to ensure consistency, coherence, and interpretive depth across cases. Peer Debriefing: All members of the research team conducted regular debriefing sessions to review coding, challenge interpretations, and ensure analytical rigor. Thick Description: Rich, contextualized excerpts from participant responses were included in the results to support transparency and transferability of findings to other similar settings. RESULTS Our analysis of the questionnaire and focus group data revealed four key factors (see Fig. 1 ) that shaped students’ experiences with team-based learning: (1) preparation and self-regulated learning, (2) understanding and valuing teamwork, (3) student motivation, and (4) attitudes toward active learning. These themes reflect the conditions under which students reported either positive or negative engagement with the TBL format (see Fig. 2 ). 1. Preparation and Self-Regulated Learning Our data consistently reflected the importance of coming to class prepared, highlighting how prior engagement with the material served as a foundational element for meaningful participation and deeper learning during TBL sessions. Students who came prepared Students who prepared in advance by reviewing lecture materials or textbooks found themselves better equipped to actively contribute during TBL sessions. Prior preparation enhanced their ability to engage in higher-order thinking, apply concepts to new scenarios, and participate more confidently in collaborative problem-solving. “I recommend they [students] learn to understand the material and never try to memorize. Understanding concepts helps with the exercises. Also, [they] must keep an open mind to other answers and provide evidence for your answer. To do all of that you really need to have a good grasp on the material and know what you are talking about.” [AQ2] “Team discussions and the way the exercises are setup; they make the application of knowledge possible rather than simply reading about it.” [AQ5] “[It’s] easier to remember lessons since I am actually using them to solve the questions [and] get to learn more from team members” [BQ6]. Students also appreciated the structured, time-limited nature of TBL sessions, particularly the focused flow of team discussions during the application exercise. The one-hour time limit encouraged efficient collaboration among team members, quick decision-making, and purposeful engagement – skills they saw as directly transferable to clinical practice. The timed nature of activities in TBL live sessions helped them develop time management and teamwork strategies essential for professional settings where timely, informed decisions are critical. “You cannot expect to have time to ‘learn’ new stuff during team discussion. It must be a review for you so that you can solve the clinical problems and get to apply the knowledge you’ve already learned. You can’t have all the time in the world to do everything that you’d like to, of course… you need to learn to manage time so you can get the most out of it.” [AF4] “It’s good practice for the future. If we are to get into the health professions, we need to learn to complete tasks under reasonable time limits.” [AF3] Additionally, self-regulated learning emerged as a critical element of success in TBL, with students noting that the format encouraged consistent engagement with the material over time. Unlike lecture-based courses that could allow for last-minute cramming, TBL’s structure with regular assessments and team accountability motivated students to develop effective study habits and manage their time more intentionally. Many found that learning in smaller, weekly chunks led to a deeper and more sustained understanding. “In a lecture-based course you don’t need to force yourself to come prepared since all you need to do is to sit in a corner for one hour... You’re not going to be graded on how you spend your time during a lecture anyway. In the end, you take a few days to cram all the information and there is actually a good chance that you end up getting a good grade… this is not the case with TBL. Here, you need to contribute in your team and you’re actually being graded on it. You can’t wait until the last minute and cram the information, so you actually need to divide your learning time and energy to a bit-by-bit format.” [AF5] “It is nice to split up the load into week-by-week chunks and stay on top of it by low-stakes quizzes and exercises in TBL sessions. It’s better than block-by-block exams in lecture-based courses.” [AF2] Students who did not come prepared In contrast to the positive and meaningful experiences described above, students who came unprepared expressed feelings of stress, frustration, and a sense of falling behind. They perceived live TBL sessions as unproductive and a poor use of their time. “The team can go faster than me without me understanding the whole process. Like, there is two hours of my time going into a TBL session while I can be just using that time reading my notes and just learning on my own.” [AF1] “You don’t get a chance to understand and follow all the reasoning that goes into each of the 8 questions. I can follow only 4 to 5 questions at my speed of processing the ideas… if something is being talked of and I am not following, then it actually has a debilitating effect on my learning.” [AF7] 2. Understanding and Valuing Teamwork Understanding the structure of team-based learning – by recognizing the value of contributing to a learning team and genuinely buying into the TBL approach – emerged as another key factor that shaped students’ overall perceptions and experiences in the course. Students who saw value in teamwork Participants who embraced TBL’s collaborative structure reported both interpersonal and academic benefits. They appreciated the balance between individual preparation and collective problem-solving, noting that working through the gRAT as a team helped them clarify misunderstandings and reinforce key concepts. Group discussions not only deepened their understanding but also exposed them to different ways of thinking, encouraging self-reflection and timely resolution of misconceptions. They also thought sharing the workload and learning alongside peers contributed to a more supportive and enriching educational experience. “I like to work through the problem with my group where we are able to bounce ideas off each other... you get to see how others process the information and how they come up with answers.” [AF4] “I like to take the gRAT with my group. Studying the material on my own, sometimes I have gaps in my understanding. Having a team fixes those gaps before exams, which I appreciate.” [AQ5] “Some groups have a more competitive approach, and different people might thrive in different settings [so,] you’re forced to reevaluate within your own self.” [BF4] Several students also linked the teamwork component of TBL to their future roles in healthcare, where collaborative skills and communication are essential: “In the field of healthcare, you are not going to work alone, it’s always going to be together with others, as part of a team, and with time constraints. TBL provides good practice for building your social skills and practicing successful group communication that are necessary for problem solving.” [AF6] “I like the concept. And I think it’s more rewarding because you’re not going to be working with people that you’re familiar with, that you have a connection to all the time, but you’re still going to have to work together.” [BF1] In addition to these practical benefits, some students described the development of a ‘team spirit’ as a particularly engaging aspect of their TBL experience. They perceived group work as educationally valuable and socially motivating for them. The sense of shared goals and light-hearted competition added energy and accountability to their learning process: “I personally enjoy the competitive aspect of being grouped in a team and working together to keep our lead in the course... This makes me study harder because I don’t want to let my teammates down.” [AQ5] “I enjoy working with my group and it helps me come to class better prepared knowing the group’s expectations of me.” [BQ3] Students who did not see value in teamwork However, not all students shared a positive view of teamwork in this study. Some expressed frustration and felt left behind when team members moved ahead without them. Others were uncomfortable relying on peers for learning, preferring direct instruction from faculty. “It is supposed to be team-based learning, but only a few people actually keep moving, leaving others behind. If I don’t get it, then I’m just wasting my time.” [AF7] “It’s not fair to learn material from my fellow students when a professor should be in charge of that” [BQ4] In addition, some students found TBL challenging when group members differed in their level of preparation or willingness to collaborate. One consequence of students feeling uncomfortable with the team-based learning format was disengagement, which others perceived as disruptive to group cohesion and overall learning. “One con [of the TBL] is that not all teammates are created equal. Meaning, not everyone studies as hard as some of the others, and that’s upsetting because it affects your team’s performance.” [AQ5] “Not everyone's voice in the group gets heard, some people are too stuck in their own thoughts to consider the ideas of others” [BQ2] 3. Motivation and Learning Behavior Motivation emerged as another key factor shaping students’ experiences with TBL. To better understand variations in engagement, we examined how differing levels of intrinsic and extrinsic motivation influenced students’ participation and perceptions of their learning experience. Students with intrinsic motivation Intrinsic motivation played a significant role in shaping students’ perceptions of TBL. Those with strong aspirations for careers in the health professions were more likely to value the collaborative and practical aspects of the TBL format, viewing it as reflective of real-world professional environments where teamwork and adaptability are essential. “The pro [of TBL] is that in the professional world you won’t be on the same page as everyone, you’ll have to work together anyway. I believe the TBL reflects this.” [BQ1] “I think that’s what is important about communication. Because in the real world, they're not going to give you a ‘pick your co-worker’. I mean, click other people and become friends… you can't just say, yeah, they're a little too loud for me so I think I'm going to work over here by myself...” [BF10] Some students also described TBL as an approach that helped them move beyond surface-level learning and the habit of studying only for the test, encouraging exploration of a broader range of content – not just what would be assessed. They reported that discussing detailed content collaboratively helped them assess their own understanding, identify gaps, and determine how to use various resources effectively. This process supported not just retention, but also the co-construction of new knowledge as they integrated insights across sessions and applied their learning in meaningful ways. This broader, more reflective engagement was especially appreciated by students who were intrinsically motivated to learn and apply their knowledge, leading to deeper comprehension and real-time application – outcomes they felt would not have been possible in traditional lecture formats. “You are like, ‘I know this; and I don't know this’, and then assess which resources you can use, and how they're going to help you later down the road. Some of that information falls right into what you might call ‘TBL-ing’.” [BF9] “Essentially, it's a connection. If I'm learning something new, I’m like, okay, well, I learned this the other day, so it's adding to this... And then, after I connect it, I really know it when I'm able to apply it. So, I connected it to this and now all of these things make sense. Now I can go and apply what I've learned to something new, and then I'm able to put everything together.” [BF8] “I did like the stuff that was out of our breadth, because then we can have this application!” [BF11] Some students were simply driven by an internal desire to succeed and viewed academic performance as a personal challenge. This intrinsic motivation shaped their engagement with TBL, prompting them to approach the material with curiosity and intention. For these students, TBL offered a meaningful learning experience aligned with their personal values and goals, rather than simply a means to earn grades. “It depends on how you process the information. People do it differently, like, what do you do with the info you just heard? Do you find it important? Think about it? Or just bury it in a corner of your mind like a coin that can buy you grades when needed?” [AF6] “The only competition that I honestly feel is with myself. When I go and I see the numbers, the averages... and I said, where did I fall? Right then, I’m just like, okay, I need to do something different.” [BF1] Students with extrinsic motivation Extrinsic motivation, driven by external rewards such as grades or exam performance, influenced how some students approached TBL. Students with lower intrinsic motivation were less likely to engage actively in TBL, especially given its low-stakes, formative structure. Some felt that since TBL activities did not directly impact their exam performance, they lacked relevance – making the sessions feel more like a task to complete than a meaningful learning opportunity for them. “Even though we need to talk through the concepts and make connections in order to learn the concepts, not everybody cares to put all the energy and time to engage in a team discussion which is not really going to help their grade in the unit exams.” [AQ5] “The assessment is over material that will never be on our exams and therefore is not relevant to us. This turns TBLs into a nuisance, and more of a ‘task to complete’.” [BQ4] 4. Attitudes Toward Active Learning The final factor that influenced students’ experiences with TBL in our study was their general attitude toward active learning. These attitudes were shaped by their prior educational experiences, personal beliefs about how human learning occurs, and perceptions of how relevant and effective the active learning strategies were in supporting their understanding of the subject matter. Students who embraced active learning Students who were open to interactive, discussion-based formats reported stronger engagement, deeper understanding, and better retention. Even those who faced challenges, such as needing accommodations, expressed a willingness to adapt and engage meaningfully in the process when they recognized the value of active learning. “I like the opportunity to work with my classmates to see how each of us interpreted the material. Many times, I have an idea on how I think something works, and once I hear someone else's interpretation of the notes, it broadens my perspective.” [BQ2] “Solving problems in a cooperative way so everyone gets to learn from each other instead of from instructors only.” [BQ6] “I get accommodation, but there is no accommodation with TBL. And so, when it comes to processing and listening, and being able to look stuff up at the same time, I struggle with everybody talking ... and to be able to also contribute, I actually have to process that information... We did a good job, but that for me, like, it's a little stressful. So, I want to make sure that I'm giving it my best.” [BF10] Students who resisted active learning Students who preferred traditional lecture-based approaches often struggled with the self-directed nature of TBL expressed discomfort with its active learning demands. Some resisted the format altogether, voicing concerns about the lack of direct instruction and requesting more structured, lecture-style support such as recorded lectures and follow-up presentations to be made available to them. This resistance highlighted a preference for passive learning and difficulty adjusting to the autonomy and collaborative expectations of team-based learning. “Prepare not to rely on the teachers. In the TBL format you’re pretty much on your own to teach yourself the whole course. There is no actual teaching of the material.” [AQ3] “It takes too much time to learn something completely on your own, besides, you may mis-learn things when there are no lectures.” [AQ4] “Science is a structured discipline, and presenting classes in a way that lacks structure is infuriating. The TBLs aren't set up to learn.” [BQ4] Students who were resistant to active learning tended to remain passive or disengaged during sessions. Their disengagement often stemmed from a belief that the format did not align with their preferred learning style or that their contributions were unnecessary, especially when more vocal team members dominated the discussions. “I personally am a visual and auditory learner. Sometimes I misunderstand concepts and spend way too much time seeking clarification.” [AF7] “I'm just saying like... if you always just pass the mic, then somebody who is good at it, they will always pick up and explain, and then everybody else don’t even need to worry.” [BF5] DISCUSSION This study explored students’ perceptions and experiences of Team-Based Learning (TBL) in a graduate-level histology course, yielding insights that underscore both the transformative potential and nuanced challenges of implementing TBL in biomedical education. By applying a critical constructivist lens, we were able to foreground the voices of learners and highlight the dynamic interplay between pedagogical design and student agency. TBL as a Catalyst for Self-Regulated Learning and Professional Readiness One of the most salient findings in this study was the role of TBL in cultivating self-regulated learning skills. Students who engaged with the material in advance reported a more rewarding experience. This aligns with Zimmerman’s model of self-regulation, which emphasizes the cyclical interplay of forethought, performance, and self-reflection (Zimmerman, 2000). These students described how the structure of weekly TBL sessions encouraged consistent study habits and deeper conceptual understanding, echoing prior research advocating for active learning formats as vehicles for sustained engagement and long-term retention (Crowe et al., 2008; Michaelsen & Sweet, 2004). Moreover, many students perceived TBL as effective preparation for their future clinical practice. The need to apply knowledge under time constraints, collaborate with peers, and adapt to diverse communication styles was seen as an authentic rehearsal of the professional competencies required in healthcare settings. These findings align with the broader literature suggesting that cooperative learning not only supports academic achievement but also promotes professional development and enhanced readiness for real-world problem-solving and collaborative practice (Johnson et al., 2007; Burgess et al., 2020; Vasan et al., 2009). In addition to promoting professional competencies, TBL fosters learning through social interaction, reflecting constructivist principles that emphasize knowledge construction through dialogue and collaboration (Vygotsky, 1994). Working in diverse teams exposes students to differing perspectives and problem-solving strategies, which in turn challenges assumptions, stimulates critical thinking, and enhances cognitive integration. The Dual Edge of Team Dynamics The study also illuminated the complexity of group-based learning. The phrase spoken by one of the participants “ not all teammates are created equal ” indirectly highlights the varying levels of student motivation to engage with the team and self-regulated learning. While some students thrived on the camaraderie, shared responsibility, and dialogic knowledge-building afforded by the team setting, others struggled with unequal participation and mismatched motivation levels. This tension underscores the importance of intentional team formation, clear role expectations, and conflict resolution strategies as highlighted in earlier TBL literature (Oakley et al., 2004; Gabelica et al., 2022). Interestingly, intrinsic motivation emerged as a moderating factor in group dynamics within students’ TBL experiences. Those who were driven by personal or professional goals found value in the format and thus tended to engage more actively. They often contributed more meaningfully, took initiative during discussions, and overall supported peer learning. Students who lacked intrinsic motivation expressed frustration or disengagement, subsequently leading to minimal contributions to the group and a less positive experience overall. These findings resonate with Dweck’s (1986) and Bandura’s (1997) work on motivation and self-efficacy, reinforcing the need for instructors to foster not only knowledge acquisition but also motivational and affective dimensions of learning. These motivational dynamics are consistent with broader theoretical distinctions between intrinsic and extrinsic motivation. Intrinsically motivated students often engage with tasks for enjoyment or curiosity, leading to more positive group interactions, while extrinsically motivated individuals may simply participate to avoid negative consequences or secure rewards (Maehr & Meyer, 1997; Graham & Weiner, 1996; Kolencik, 2014; Kohn, 1999). This distinction affects the quality of engagement and the ability of students to become self-directed learners, an essential skill for success in team-based learning (Bandura, 1977; Zimmerman, 2014). Resistance to Active Learning: A Pedagogical Barrier Another theme that surfaced was resistance to active learning. Students with strong preferences for passive learning modalities (e.g., lectures, structured content delivery) were less likely to embrace the cognitive and social demands of TBL. This resistance often stemmed from discomfort with ambiguity, a lack of confidence in peer-led discussions, misalignment with prior educational experiences, or a discomfort with the weight of responsibility the learner feels to teach themselves in preparation for the TBL sessions. Similar resistance patterns have been reported in literature examining transitions from traditional to active pedagogies (Vasan et al., 2009; Haidet et al., 2012). This points to a broader pedagogical challenge: the need to scaffold the transition from passive into active learning, especially for students with limited exposure to such formats. Providing preparatory resources, clear rationale for the TBL structure, and early peer support may ease the adjustment and reduce initial friction (Clark et al., 2008; Freire, 2000). Indeed, when students are unfamiliar with self-directed learning, the experience can be disorienting. Freire’s (1970, 2000) critique of the "banking model", where students passively receive knowledge from instructors, helps contextualize this discomfort. In contrast, TBL reflects a "problem-posing" approach, positioning students as co-creators of knowledge through active participation and dialogue. This learner-centered model fosters critical thinking, collaboration, and deeper cognitive engagement (Kincheloe, 2005). To ease the transition for students – many of whom may be unfamiliar the active learning demands of the TBL structure, which is grounded in a constructivist learning paradigm – transparent communication about the goals and structure of TBL format is essential. When students understand the instructional logic behind a new format, they are more likely to engage productively with it (Schwarz, 2013). Implications for Practice The findings of this study have several practical implications. First, designing TBL sessions that integrate formative assessment and collaborative learning can foster deeper engagement, provided students are adequately supported and prepared. Second, ongoing instructor involvement through feedback, regular check-ins, and attentiveness to student concerns can help alleviate both interpersonal difficulties and the cognitive demands of grappling with complex material in team-based environments. Finally, integrating student voices into the evaluation and iterative refinement of TBL structures is essential. As this study shows, students offer critical insights into what works, what doesn’t, and why – insights that are often overlooked in more traditional top-down educational designs. Limitations and Future Directions Despite its many benefits, our study was limited to a single institution and a specific course, which may restrict the generalizability of findings. While qualitative depth was prioritized here, future research could triangulate these findings with quantitative data (e.g., academic outcomes, performance metrics) across multiple institutions. Additionally, exploring faculty perceptions and institutional constraints would offer a more holistic view of TBL implementation in graduate and medical education. Future investigations might also expand to include diverse student populations across undergraduate and professional programs, thereby improving the transferability and contextual relevance of findings. Employing thick description and multi-site comparisons could enhance the external validity of future research and foster best practices across settings. CONCLUSIONS This study highlights the potential of Team-Based Learning (TBL) to enhance active engagement, self-regulated learning, and collaborative problem-solving in biomedical education. Grounded in constructivist learning theory, TBL supports students in integrating new knowledge through collaborative learning while developing some of the essential competencies required in professional practice, such as communication, critical thinking, and teamwork. However, the effectiveness of TBL is influenced by several factors, including student motivation, team dynamics, and prior exposure to active learning methodologies. To better navigate these challenges and maximize the impact of TBL, thoughtful design, clear guidance from instructors, and strong institutional support are critical. A well-organized and supportive learning environment ensures that students can fully engage with the TBL process and realize its potential benefits. When implemented effectively, TBL offers a meaningful and transformative learning experience that not only enhances academic outcomes but also prepares students for the complex and collaborative demands of healthcare professions. Declarations Ethics approval and consent to participate : All procedures performed in this study have been performed following the Declaration of Helsinki. This study was reviewed and granted the “exempt” status by the Institutional Review Board (IRB) at Indiana University (protocol # 1709463378). All participants involved in the study were invited to participate voluntarily. The need for written informed consent to participate was waived by the IRB. Consent for publication : No copyright figures, tables, or data collection instruments in the manuscript have been used. All work is original and therefore no permissions need to be obtained. Funding: The authors did not receive support from any organization for the submitted work. Author Contribution HA designed the study and collected the data. HA, YM, HM, and RL conducted the initial data analysis. CN, DB and SH drafted the manuscript. HA supervised data analysis and manuscript preparation. All authors interpreted the results, provided feedback on earlier drafts, read and approved the final manuscript and agreed to submit it to the journal. Acknowledgement We wish to thank James Brokaw, PhD, MPH, and Kyle Robertson, PhD, for reading the earlier drafts of this manuscript and providing constructive feedback. We also acknowledge the Research Scholar Program at the College of Science and Technology, Temple University, for supporting the involvement of undergraduate mentees who served as research assistants in this study. In particular, we thank Sulaiman Sharief for his contributions to data processing and organization. Availability of data and materials: Majority of data generated and analyzed during this study are included in this published article. Complete raw datasets generated in this study are available from the corresponding author on reasonable request. References Anfara, V. A., & Mertz, N. T. (Eds.). (2015). Theoretical frameworks in qualitative research (2nd ed.). SAGE Publications. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavior change. Psychological Review, 84 (2), 191–215. Bandura, A. (1997). Self-efficacy: The exercise of control . W. H. Freeman. Bonner, D., & Kovach, J. V. (1996). Self-regulated learning in college students: Use of learning strategies, motivation, and performance. Psychological Reports, 78 , 691–698. Burgess, A., Bleasel, J., Hickson, J., Guler, C., Kalman, E., & Haq, I. (2020). Team-based learning replaces problem-based learning at a large medical school. BMC Medical Education, 20 , 1–8. https://doi.org/10.1186/s12909-020-02022-3 Clark, M. C., Nguyen, H. T., Bray, C., & Levine, R. E. (2008). Team-based learning in an undergraduate nursing course. Journal of Nursing Education, 47 (3), 111–117. Crowe, A., Dirks, C., & Wenderoth, M. P. (2008). Biology in Bloom: Implementing Bloom’s taxonomy to enhance student learning in biology. CBE—Life Sciences Education, 7 (4), 368–381. Dweck, C. S. (1986). Motivational processes affecting learning. American Psychologist, 41 (10), 1040–1048. Freire, P. (2000). Pedagogy of the oppressed (30th anniversary ed.). Continuum. Gabelica, C., De Maeyer, S., & Schippers, M. C. (2022). Taking a free ride: How team learning affects social loafing. Journal of Educational Psychology, 114 (4), 716–733. Graham, S., & Weiner, B. (1996). Theories and principles of motivation. In D. C. Berliner & R. C. Calfee (Eds.), Handbook of educational psychology (pp. 63–84). Macmillan. Goodman, G. S. (2014). Coming to critical constructivism: Roots and branches. In G. S. Goodman (Ed.), Educational psychology reader: The art and science of how people learn (pp. 1–16). Peter Lang. Grbich, C. (2012). Qualitative data analysis: An introduction (2nd ed.). SAGE. Haidet, P., Levine, R. E., Parmelee, D. X., Crow, S., Kennedy, F., Kelly, P. A., ... & Richards, B. F. (2012). Perspective: Guidelines for reporting team-based learning activities in the medical and health sciences education literature. Academic Medicine, 87 (3), 292–299. Haberyan, A. (2007). Team-based learning in an industrial/organizational psychology course. North American Journal of Psychology, 9 , 143–152. Hawi, R. (2017). Implementation of Team Based Learning (TBL) in a Lebanese medical school. Journal of Comparative & International Higher Education, 9 (2), 23–30. Jabbar, A., Maqbool, S., & Zafar, M. (2018). Student satisfaction and self-regulated learning: Role of academic motivation. Pakistan Journal of Psychological Research, 33 (1), 229–244. Johnson, D. W., Johnson, R. T., & Smith, K. A. (2007). The state of cooperative learning in postsecondary and professional settings. Educational Psychology Review, 19 , 15–29. Kincheloe, J. L. (2005). Critical constructivism primer . Peter Lang. Kohn, A. (1999). The schools our children deserve: Moving beyond traditional classrooms and “tougher standards” . Houghton Mifflin. Koles, P. G., Stolfi, A., Borges, N. J., Nelson, S., & Parmelee, D. X. (2010). The impact of team-based learning on medical students’ academic performance. Academic Medicine, 85 (11), 1739–1745. Kolencik, P. (2014). Motivating struggling learners: 10 ways to build student success . Rowman & Littlefield. Levine, R. E., & Hudes, P. (2021). Team-based learning: From theory to practice in medical education. In M. S. Kindler (Ed.), Teaching and learning in medical education (pp. 109–124). Springer. Li, X., Zha, S., Estis, J., & Wu, S. (2021). Advancing engineering students’ technical writing skills by implementing team-based learning instructional modules in an existing laboratory curriculum. Education Sciences, 11 (12), 820. https://doi.org/10.3390/educsci11120820 Maehr, M. L., & Meyer, H. A. (1997). Understanding motivation and schooling: Where we've been, where we are, and where we need to go. Educational Psychology Review, 9 (4), 371–409. https://doi.org/10.1023/A:1024750807365 Michaelsen, L. K., & Sweet, M. (2004). The essential elements of team-based learning. New Directions for Teaching and Learning, 2004 (116), 7–27. Oakley, B., Felder, R. M., Brent, R., & Elhajj, I. (2004). Turning student groups into effective teams. Journal of Student Centered Learning, 2 (1), 9–34. Park, E. H., & Park, M. (2021). Designing and implementing a team-based learning module in pharmacology. Korean Journal of Medical Education, 33 (1), 21–30. Piaget, J. (1971). The theory of stages in cognitive development . In D. R. Green, M. P. Ford, & G. B. Flamer (Eds.), Measurement and Piaget (pp. 1–11). McGraw-Hill. Schwarz, R. M. (2013). Smart leaders, smarter teams: How you and your team get unstuck to get results . Jossey-Bass. Searby, M., & Ewers, T. (1997). Peer coaching for change: Facilitating the development of learner-centered teaching. Community College Review, 25 (2), 27–44. Silva, A. K., Teixeira, L. F. M., & Silva, J. V. L. (2021). Team-based learning and student engagement in higher education. Educational Research and Reviews, 16 (3), 89–96. Thomas, P. A., Mitchell, M. M., & Joseph, C. M. (2002). Team-based learning and learning style. Journal of Instructional Psychology, 29 (1), 49–54. Van den Bossche, P., Gijselaers, W. H., Segers, M., & Kirschner, P. A. (2006). Social and cognitive factors driving team learning: Team learning beliefs and behaviors. Learning and Instruction, 16 (6), 523–538. Vasan, N. S., DeFouw, D. O., & Holland, B. K. (2009). Modified use of team-based learning for effective delivery of medical gross anatomy and embryology. Anatomical Sciences Education, 2 (1), 3–9. Veneri, D. A., & Mongillo, E. A. (2021). Transforming student learning with team-based learning: Application across disciplines. College Teaching, 69 (4), 223–231. Vygotsky, L. S. (1994). The problem of the environment. In R. Van der Veer & J. Valsiner (Eds.), The Vygotsky reader (pp. 338–354). Blackwell. Watkins, K., Forge, N., Lewinson, T., & Greenwald, L. (2018). Undergraduate social work students’ perceptions of a team-based learning approach to exploring adult development. Journal of Social Work Education, 54 (1), 1–13. Zimmerman, B. J. (2000). Attaining self-regulation: A social cognitive perspective. In M. Boekaerts, P. R. Pintrich, & M. Zeidner (Eds.), Handbook of self-regulation (pp. 13–39). Academic Press. Zimmerman, B. J. (2014). Self-regulated learning: Theories, measures, and outcomes. In D. H. Schunk & J. A. Greene (Eds.), Handbook of self-regulation of learning and performance (2nd ed., pp. 49–64). Routledge. Additional Declarations No competing interests reported. Supplementary Files Focusgroupprotocol.docx QuestionnaireInstrument.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6658854","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":482146969,"identity":"8ddaab80-3873-4dbb-8e30-1121427c5d4e","order_by":0,"name":"Homaira M. 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Henderson","email":"","orcid":"","institution":"Drexel University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Skylar","middleName":"J.","lastName":"Henderson","suffix":""}],"badges":[],"createdAt":"2025-05-13 22:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6658854/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6658854/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86386610,"identity":"c3b5efd9-e0ce-4647-bc92-3a79bea83647","added_by":"auto","created_at":"2025-07-10 06:00:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47576,"visible":true,"origin":"","legend":"\u003cp\u003eKey Factors Influencing Student Experience in Team-Based Learning\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6658854/v1/128f3038d8cdce43312dd8b8.png"},{"id":86387232,"identity":"14da1a0b-8e97-409a-8aaf-3e86d370308c","added_by":"auto","created_at":"2025-07-10 06:08:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":284241,"visible":true,"origin":"","legend":"\u003cp\u003eSummary of results\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6658854/v1/469e0c06358685d730c53d4b.png"},{"id":90762789,"identity":"cb378ce4-134a-42fd-81f0-5a26e30295f1","added_by":"auto","created_at":"2025-09-07 16:08:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1186166,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6658854/v1/8b154dc8-c5bd-418b-9d20-fa8b050b9110.pdf"},{"id":86386612,"identity":"60eb1a81-f723-4d4c-a35b-d9211e24086e","added_by":"auto","created_at":"2025-07-10 06:00:13","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16070,"visible":true,"origin":"","legend":"","description":"","filename":"Focusgroupprotocol.docx","url":"https://assets-eu.researchsquare.com/files/rs-6658854/v1/766e9ea5e48d696ac866ee59.docx"},{"id":86386611,"identity":"641bf2ec-18fa-45e7-a4c2-388628ac6196","added_by":"auto","created_at":"2025-07-10 06:00:13","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15771,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionnaireInstrument.docx","url":"https://assets-eu.researchsquare.com/files/rs-6658854/v1/21d7f7dceeeba1866ceaa10b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Resistance to Engagement: Factors That Influence Student Outcomes in Team-Based Learning","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eTeam-Based Learning (TBL), originally developed in the 1970s by Larry Michaelsen, has emerged as a powerful approach to promote active learning through structured small-group work under instructor guidance (Levine \u0026amp; Hudes, 2021). While often positioned as an alternative to traditional large-group lectures, TBL can also serve as a valuable supplement to lectures, enhancing student engagement and understanding.\u003c/p\u003e\u003cp\u003eThe traditional TBL format requires pre-class student preparation, an individual readiness assurance test (iRAT), a group readiness assurance test (gRAT), and concludes with whole-class discussion and instructor feedback. This structure effectively shifts the instructor\u0026rsquo;s role from content deliverer to learning facilitator (Koles et al., 2010; Michaelsen \u0026amp; Sweet, 2004; Silva et al., 2021). To fully realize the benefits of this instructional approach, creating a supportive learning environment is critical, as the potential of TBL to deepen content comprehension and improve academic outcomes depends on student participation and active engagement (Burgess, 2020; Hawi, 2017). The inclusion of formative assessment components, such as the iRAT and gRAT, further supports this engagement by encouraging accountability and collaboration throughout the learning process (Jabbar et al., 2018).\u003c/p\u003e\u003cp\u003eIn medical education, there has been a shift towards TBL integration within many institutions, with utilization across multiple medical subjects (Burgess et al., 2020). More recently, other disciplines have also begun adopting aspects of the TBL format through diverse formats such as weekly modules, vocabulary assessments, and collaborative assignments, highlighting the model\u0026rsquo;s versatility and adaptability (Li et al., 2021; Park \u0026amp; Park, 2021; Veneri \u0026amp; Mongillo, 2021). Although TBL has the potential to offer wide-ranging benefits \u0026ndash; including enhanced engagement, deeper content comprehension, and improved academic outcomes \u0026ndash; its implementation is not without challenges. A transition from didactic lectures to educating through a TBL format often requires greater institutional support and additional resources. For example, more teaching assistants, clinician involvement, and extra time may be needed for student familiarization with the new structure (Hern\u0026aacute;ndez, 2021). These demands can put pressure on budgets and staffing, which can then affect the quality and consistency of TBL delivery (Burgess et al., 2020).\u003c/p\u003e\u003cp\u003eWhile TBL aims to enhance engagement, not all students respond positively to the increased demand for active participation. Some common problems include procrastination, unequal participation, and interpersonal conflicts, which can lead to increased student stress and diminished learning outcomes (Watkins et al., 2018). Disproportionate student contributions and challenges in peer collaboration often result in imbalanced workloads and increased team tension (Gabelica et al., 2022). Moreover, navigating differences in personalities and levels of commitment can also detract from the learning experience (Johnson et al, 2007). This emphasizes the need for strategies that can promote more balanced participation while minimizing group conflict (Van den Bossche et al., 2006).\u003c/p\u003e\u003cp\u003eAside from group dynamics, the self-directed nature of TBL can also pose challenges for some students. The shift to student-centered engagement often results in initial discomfort or resistance for some (Vasanet al., 2009). Students accustomed to passive, primarily lecture-based learning environments may struggle with the greater responsibility required of them in an active learning setting. For those unfamiliar with the TBL model, the expectation to engage actively and meaningfully in a small group can be overwhelming, particularly during first exposure to the format (Thomas, Mitchell, \u0026amp; Joseph, 2002; Haberyan, 2007).\u003c/p\u003e\u003cp\u003eTo address some of these concerns, educators have adopted various strategies to foster a more supportive and productive TBL environment. Structured team-building exercises and routine peer evaluations have been found to be effective in promoting communication and collaboration among students (Michaelsen et al., 2004; Searby \u0026amp; Ewers, 1997). Providing clear guidelines on team roles and expectations can also help reduce conflict and promote more equitable student participation (Johnson et al., 2007; Oakley et al., 2004). Additionally, formative assessments, i.e., the iRAT and gRAT, allow instructors to monitor individual student progress and provide them with timely feedback (Michaelsen et al., 2004). As mentioned before, a well-organized and supportive environment is crucial for fully realizing TBL\u0026rsquo;s potential to enhance learning outcomes (Van den Bossche et al., 2006).\u003c/p\u003e\u003cp\u003eTo further mitigate resistance to active learning, the literature suggests offering continuous encouragement through instructor feedback sessions, regular check-ins with teams and individual students, and maintaining open channels for students to be able to express any concerns (Haidet et al., 2012). Peer mentoring and testimonials from students who previously succeeded in TBL settings have also shown promise in easing student anxieties and leading to greater participation (Clark et al., 2008).\u003c/p\u003e\u003cp\u003eDespite the strategies proposed in literature, challenges with student engagement and resistance in TBL environments persist. Building on the existing solutions, this study aimed to explore, in more depth, how students experience participation in TBL sessions. Specifically, we sought to understand where and why resistance may arise and the underlying reasons for student disengagement and suboptimal academic outcomes. Using a qualitative approach, this study captured the nuanced perspectives of students as they navigated the demands of a graduate-level histology course that used the TBL format. The findings of this study offer valuable implications for instructional design and student support to create more meaningful and successful learning experiences for all students in health sciences education.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eConceptual Framework\u003c/h2\u003e\u003cp\u003eThis study is grounded in two levels of theory (Anfara \u0026amp; Merz, 2015). At the grand conceptual level, it draws on critical constructivist theory (Piaget, 1971; Goodman, 2014; Kincheloe, 2005), which determined our research focus, philosophical paradigm (constructionism), formulation of the research question, and the overall methodological approach. At the micro level, additional theoretical and analytical concepts that were used to interpret the data include the Freirian concepts of banking education and problem-posing education (Freire, 2000), intrinsic motivation (Dweck, 1986; Kolencik, 2014) and self-regulated learning (Zimmerman, 2000; Bonner \u0026amp; Kovach, 1996).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy setting and participants\u003c/h3\u003e\n\u003cp\u003eThis study involved two student cohorts (Cohort A and Cohort B) who were enrolled in the same graduate-level histology course at different times. This was a required course within the Master of Medical Sciences program at one medical school. Most students enrolled in the program were aspiring medical students planning to apply to medical school the following year. A total of 55 students were enrolled across the two cohorts (n\u0026thinsp;=\u0026thinsp;28 in Cohort A, and n\u0026thinsp;=\u0026thinsp;27 in Cohort B). Each cohort was taught by a different team of faculty instructors; however, the course content, TBL format, and curriculum were the same. The data collection instruments, including the questionnaire and focus group protocol, were also identical across both cohorts.\u003c/p\u003e\u003cp\u003eTBL sessions were conducted once a week during the semester course for a total of 10 sessions. During each session, students took the iRAT and then gRAT quizzes (10 multiple-choice questions per quiz) at the beginning of each session (~\u0026thinsp;25 minutes) and worked on the application exercise for the rest of time (~\u0026thinsp;2 hours). Application exercises had two components:1) Team discussion (1 hour), during which each student team worked through the 8 clinical case-scenario questions provided in the application exercise, 2) Faculty debriefing session (~\u0026thinsp;1 hour), which involved a whole-class discussion of the correct and incorrect answers facilitated by course faculty. Assessments conducted during the TBL sessions accounted for 30% of the final course grade, divided as follows: iRAT 10%, gRAT 5%, and application exercises 15%.\u003c/p\u003e\u003cp\u003eThe entire application exercise session was held in a testing environment, where students were not allowed to connect to the internet, use their cell phones, or leave the room. The only resources allowed were the course textbook, a medical dictionary, and a copy of Merck\u0026rsquo;s Manual, all of which were provided as hard copies at each discussion table.\u003c/p\u003e\u003cp\u003eStudents were randomly grouped into four teams (6\u0026ndash;7 students) on the first day of the class and worked with the same team throughout the semester. The performance of the teams during each session was recorded based on the number of correct answers during the application exercises. At the end of each session, the top performing teams were recognized. However, this determination was used only to promote teamwork and engagement with the TBL format and did not contribute to the students\u0026rsquo; final course grade.\u003c/p\u003e\n\u003ch3\u003eData Generation\u003c/h3\u003e\n\u003cp\u003eData collection methods used in this study included qualitative questionnaires and focus group interviews\u003c/p\u003e\u003cp\u003eThe questionnaire was designed with the goal of identifying basic overarching themes to inform the focus group protocol. All students enrolled in the course (n\u0026thinsp;=\u0026thinsp;28 in Cohort A, and n\u0026thinsp;=\u0026thinsp;27 in Cohort B) were invited to complete the questionnaire form, which was shared via the course Canvas (learning management system). The 7 open-ended questions (drafted by HA) asked about students\u0026rsquo; perceptions and experiences with the TBL format (see Questionnaire instrument in supplementary material). Participation was completely voluntary and anonymous, and no incentives (e.g., extra credit) were offered. 11 students completed the questionnaire (5 in Cohort A and 6 in Cohort B).\u003c/p\u003e\u003cp\u003eTwo focus groups were conducted \u0026ndash; one with Cohort A and one with Cohort B. Each session lasted approximately one hour and was held in person. All students enrolled in the course were invited to take part in a focus group via an announcement on the course Canvas page. Following this invitation, 20 students from Cohort A and 21 from Cohort B volunteered to participate. From this pool, 18 students were selected \u0026ndash; 7 from Cohort A and 11 from Cohort B \u0026ndash; using purposive sampling to ensure diverse representation in terms of age, gender, race/ethnicity, and academic performance (including students with A, B, and C grades) A free lunch was offered to all participants. Self-reported demographic data of the focus group participants are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of students participating in both focus groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemographics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge range (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u0026ndash;28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRace/Ethnicity (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLatino\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle Eastern\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFocus group interviews were conducted using a semi-structured protocol consisting of 6 open-ended questions (see Focus Group protocol in the supplementary material). Sessions were audio recorded and transcribed by Zoom/Otter Live Notes (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://otter.ai/zoom\u003c/span\u003e\u003cspan address=\"https://otter.ai/zoom\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The initial transcripts were then checked for accuracy and corrected by members of the research team (HA for Cohort A; RL for Cohort B).\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eAll data were anonymized and assigned unique participant identifiers to ensure confidentiality during analysis. Participants\u0026rsquo; ID codes used a combination of their cohort (A or B) and the data collection method \u0026ndash; \u0026lsquo;Q\u0026rsquo; for questionnaire and \u0026lsquo;F\u0026rsquo; for focus group. For example, \u0026ldquo;BF4\u0026rdquo; refers to participant number 4 from Cohort B who took part in a focus group. This coding system is also used to reference data excerpts throughout the results section in this paper.\u003c/p\u003e\u003cp\u003eThe data collected through questionnaires were well-suited for frame analysis (Grbich, 2012). With 11 students responding to each of the 7 questions, the dataset was automatically segmented into 77 original response units (frames). Responses were grouped by question (Qu1 through Qu7) into seven categories, which the research team reviewed both individually and collaboratively, coding for emerging themes. The overarching themes identified through this frame analysis were then used to develop a set of taxonomies, which served as an analytical matrix for examining the focus group data through a taxonomic analysis (Grbich, 2012). An abductive, hybrid coding plan, combining inductive (data-driven) and deductive (theory-driven) approaches, guided the analysis. This method enabled the integration of theoretical constructs from the study\u0026rsquo;s critical constructivist framework while remaining open to emergent themes and subthemes within the data.\u003c/p\u003e\u003cp\u003eTo enhance the credibility and transferability of our findings, we incorporated the following methodological strategies:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eTriangulation and Cross-Case Analysis: Multiple forms of triangulation were employed to strengthen the credibility and analytical rigor of the study. \u003cem\u003eMethod triangulation\u003c/em\u003e involved collecting data through two distinct approaches \u0026ndash; anonymous questionnaires and focus group interviews \u0026ndash; from the same population. \u003cem\u003eTheory triangulation\u003c/em\u003e was achieved during data interpretation by applying diverse theoretical and conceptual lenses, including critical constructivism, Freirean pedagogy, intrinsic motivation, and self-regulated learning theory. \u003cem\u003eAnalyst triangulation\u003c/em\u003e and cross-case analysis were incorporated by analyzing data from each cohort separately, allowing for within- and across-group comparisons. For Cohort A, initial coding was performed independently by HA and then reviewed and enhanced by DB and SH, who provided feedback and suggested refinements. For Cohort B, HA, YM, and HM each conducted independent analyses before reconciling their individual findings. The final analysis for both cohorts was reviewed by DB and HA to ensure consistency, coherence, and interpretive depth across cases.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e Peer Debriefing: All members of the research team conducted regular debriefing sessions to review coding, challenge interpretations, and ensure analytical rigor.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e Thick Description: Rich, contextualized excerpts from participant responses were included in the results to support transparency and transferability of findings to other similar settings.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eOur analysis of the questionnaire and focus group data revealed four key factors (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) that shaped students\u0026rsquo; experiences with team-based learning: (1) preparation and self-regulated learning, (2) understanding and valuing teamwork, (3) student motivation, and (4) attitudes toward active learning. These themes reflect the conditions under which students reported either positive or negative engagement with the TBL format (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e1. Preparation and Self-Regulated Learning\u003c/h2\u003e\u003cp\u003eOur data consistently reflected the importance of coming to class prepared, highlighting how prior engagement with the material served as a foundational element for meaningful participation and deeper learning during TBL sessions.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudents who came prepared\u003c/h3\u003e\n\u003cp\u003eStudents who prepared in advance by reviewing lecture materials or textbooks found themselves better equipped to actively contribute during TBL sessions. Prior preparation enhanced their ability to engage in higher-order thinking, apply concepts to new scenarios, and participate more confidently in collaborative problem-solving.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I recommend they [students] learn to understand the material and never try to memorize. Understanding concepts helps with the exercises. Also, [they] must keep an open mind to other answers and provide evidence for your answer. To do all of that you really need to have a good grasp on the material and know what you are talking about.\u0026rdquo; [AQ2]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Team discussions and the way the exercises are setup; they make the application of knowledge possible rather than simply reading about it.\u0026rdquo; [AQ5]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[It\u0026rsquo;s] easier to remember lessons since I am actually using them to solve the questions [and] get to learn more from team members\u0026rdquo; [BQ6].\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eStudents also appreciated the structured, time-limited nature of TBL sessions, particularly the focused flow of team discussions during the application exercise. The one-hour time limit encouraged efficient collaboration among team members, quick decision-making, and purposeful engagement \u0026ndash; skills they saw as directly transferable to clinical practice. The timed nature of activities in TBL live sessions helped them develop time management and teamwork strategies essential for professional settings where timely, informed decisions are critical.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You cannot expect to have time to \u0026lsquo;learn\u0026rsquo; new stuff during team discussion. It must be a review for you so that you can solve the clinical problems and get to apply the knowledge you\u0026rsquo;ve already learned. You can\u0026rsquo;t have all the time in the world to do everything that you\u0026rsquo;d like to, of course\u0026hellip; you need to learn to manage time so you can get the most out of it.\u0026rdquo; [AF4]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s good practice for the future. If we are to get into the health professions, we need to learn to complete tasks under reasonable time limits.\u0026rdquo; [AF3]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, self-regulated learning emerged as a critical element of success in TBL, with students noting that the format encouraged consistent engagement with the material over time. Unlike lecture-based courses that could allow for last-minute cramming, TBL\u0026rsquo;s structure with regular assessments and team accountability motivated students to develop effective study habits and manage their time more intentionally. Many found that learning in smaller, weekly chunks led to a deeper and more sustained understanding.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In a lecture-based course you don\u0026rsquo;t need to force yourself to come prepared since all you need to do is to sit in a corner for one hour... You\u0026rsquo;re not going to be graded on how you spend your time during a lecture anyway. In the end, you take a few days to cram all the information and there is actually a good chance that you end up getting a good grade\u0026hellip; this is not the case with TBL. Here, you need to contribute in your team and you\u0026rsquo;re actually being graded on it. You can\u0026rsquo;t wait until the last minute and cram the information, so you actually need to divide your learning time and energy to a bit-by-bit format.\u0026rdquo; [AF5]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is nice to split up the load into week-by-week chunks and stay on top of it by low-stakes quizzes and exercises in TBL sessions. It\u0026rsquo;s better than block-by-block exams in lecture-based courses.\u0026rdquo; [AF2]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eStudents who did not come prepared\u003c/h3\u003e\n\u003cp\u003eIn contrast to the positive and meaningful experiences described above, students who came unprepared expressed feelings of stress, frustration, and a sense of falling behind. They perceived live TBL sessions as unproductive and a poor use of their time.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The team can go faster than me without me understanding the whole process. Like, there is two hours of my time going into a TBL session while I can be just using that time reading my notes and just learning on my own.\u0026rdquo; [AF1]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You don\u0026rsquo;t get a chance to understand and follow all the reasoning that goes into each of the 8 questions. I can follow only 4 to 5 questions at my speed of processing the ideas\u0026hellip; if something is being talked of and I am not following, then it actually has a debilitating effect on my learning.\u0026rdquo; [AF7]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2. Understanding and Valuing Teamwork\u003c/h2\u003e\u003cp\u003eUnderstanding the structure of team-based learning \u0026ndash; by recognizing the value of contributing to a learning team and genuinely buying into the TBL approach \u0026ndash; emerged as another key factor that shaped students\u0026rsquo; overall perceptions and experiences in the course.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eStudents who saw value in teamwork\u003c/h2\u003e\u003cp\u003eParticipants who embraced TBL\u0026rsquo;s collaborative structure reported both interpersonal and academic benefits. They appreciated the balance between individual preparation and collective problem-solving, noting that working through the gRAT as a team helped them clarify misunderstandings and reinforce key concepts. Group discussions not only deepened their understanding but also exposed them to different ways of thinking, encouraging self-reflection and timely resolution of misconceptions. They also thought sharing the workload and learning alongside peers contributed to a more supportive and enriching educational experience.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I like to work through the problem with my group where we are able to bounce ideas off each other... you get to see how others process the information and how they come up with answers.\u0026rdquo; [AF4]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I like to take the gRAT with my group. Studying the material on my own, sometimes I have gaps in my understanding. Having a team fixes those gaps before exams, which I appreciate.\u0026rdquo; [AQ5]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Some groups have a more competitive approach, and different people might thrive in different settings [so,] you\u0026rsquo;re forced to reevaluate within your own self.\u0026rdquo; [BF4]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSeveral students also linked the teamwork component of TBL to their future roles in healthcare, where collaborative skills and communication are essential:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In the field of healthcare, you are not going to work alone, it\u0026rsquo;s always going to be together with others, as part of a team, and with time constraints. TBL provides good practice for building your social skills and practicing successful group communication that are necessary for problem solving.\u0026rdquo; [AF6]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I like the concept. And I think it\u0026rsquo;s more rewarding because you\u0026rsquo;re not going to be working with people that you\u0026rsquo;re familiar with, that you have a connection to all the time, but you\u0026rsquo;re still going to have to work together.\u0026rdquo; [BF1]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn addition to these practical benefits, some students described the development of a \u0026lsquo;team spirit\u0026rsquo; as a particularly engaging aspect of their TBL experience. They perceived group work as educationally valuable and socially motivating for them. The sense of shared goals and light-hearted competition added energy and accountability to their learning process:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I personally enjoy the competitive aspect of being grouped in a team and working together to keep our lead in the course... This makes me study harder because I don\u0026rsquo;t want to let my teammates down.\u0026rdquo; [AQ5]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I enjoy working with my group and it helps me come to class better prepared knowing the group\u0026rsquo;s expectations of me.\u0026rdquo; [BQ3]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eStudents who did not see value in teamwork\u003c/h2\u003e\u003cp\u003eHowever, not all students shared a positive view of teamwork in this study. Some expressed frustration and felt left behind when team members moved ahead without them. Others were uncomfortable relying on peers for learning, preferring direct instruction from faculty.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is supposed to be team-based learning, but only a few people actually keep moving, leaving others behind. If I don\u0026rsquo;t get it, then I\u0026rsquo;m just wasting my time.\u0026rdquo; [AF7]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s not fair to learn material from my fellow students when a professor should be in charge of that\u0026rdquo; [BQ4]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn addition, some students found TBL challenging when group members differed in their level of preparation or willingness to collaborate. One consequence of students feeling uncomfortable with the team-based learning format was disengagement, which others perceived as disruptive to group cohesion and overall learning.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;One con [of the TBL] is that not all teammates are created equal. Meaning, not everyone studies as hard as some of the others, and that\u0026rsquo;s upsetting because it affects your team\u0026rsquo;s performance.\u0026rdquo; [AQ5]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Not everyone's voice in the group gets heard, some people are too stuck in their own thoughts to consider the ideas of others\u0026rdquo; [BQ2]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3. Motivation and Learning Behavior\u003c/h2\u003e\u003cp\u003eMotivation emerged as another key factor shaping students\u0026rsquo; experiences with TBL. To better understand variations in engagement, we examined how differing levels of intrinsic and extrinsic motivation influenced students\u0026rsquo; participation and perceptions of their learning experience.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eStudents with intrinsic motivation\u003c/h2\u003e\u003cp\u003eIntrinsic motivation played a significant role in shaping students\u0026rsquo; perceptions of TBL. Those with strong aspirations for careers in the health professions were more likely to value the collaborative and practical aspects of the TBL format, viewing it as reflective of real-world professional environments where teamwork and adaptability are essential.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The pro [of TBL] is that in the professional world you won\u0026rsquo;t be on the same page as everyone, you\u0026rsquo;ll have to work together anyway. I believe the TBL reflects this.\u0026rdquo; [BQ1]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that\u0026rsquo;s what is important about communication. Because in the real world, they're not going to give you a \u0026lsquo;pick your co-worker\u0026rsquo;. I mean, click other people and become friends\u0026hellip; you can't just say, yeah, they're a little too loud for me so I think I'm going to work over here by myself...\u0026rdquo; [BF10]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome students also described TBL as an approach that helped them move beyond surface-level learning and the habit of studying only for the test, encouraging exploration of a broader range of content \u0026ndash; not just what would be assessed. They reported that discussing detailed content collaboratively helped them assess their own understanding, identify gaps, and determine how to use various resources effectively. This process supported not just retention, but also the co-construction of new knowledge as they integrated insights across sessions and applied their learning in meaningful ways. This broader, more reflective engagement was especially appreciated by students who were intrinsically motivated to learn and apply their knowledge, leading to deeper comprehension and real-time application \u0026ndash; outcomes they felt would not have been possible in traditional lecture formats.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You are like, \u0026lsquo;I know this; and I don't know this\u0026rsquo;, and then assess which resources you can use, and how they're going to help you later down the road. Some of that information falls right into what you might call \u0026lsquo;TBL-ing\u0026rsquo;.\u0026rdquo; [BF9]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Essentially, it's a connection. If I'm learning something new, I\u0026rsquo;m like, okay, well, I learned this the other day, so it's adding to this... And then, after I connect it, I really know it when I'm able to apply it. So, I connected it to this and now all of these things make sense. Now I can go and apply what I've learned to something new, and then I'm able to put everything together.\u0026rdquo; [BF8]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I did like the stuff that was out of our breadth, because then we can have this application!\u0026rdquo; [BF11]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome students were simply driven by an internal desire to succeed and viewed academic performance as a personal challenge. This intrinsic motivation shaped their engagement with TBL, prompting them to approach the material with curiosity and intention. For these students, TBL offered a meaningful learning experience aligned with their personal values and goals, rather than simply a means to earn grades.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It depends on how you process the information. People do it differently, like, what do you do with the info you just heard? Do you find it important? Think about it? Or just bury it in a corner of your mind like a coin that can buy you grades when needed?\u0026rdquo; [AF6]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The only competition that I honestly feel is with myself. When I go and I see the numbers, the averages... and I said, where did I fall? Right then, I\u0026rsquo;m just like, okay, I need to do something different.\u0026rdquo; [BF1]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eStudents with extrinsic motivation\u003c/h2\u003e\u003cp\u003eExtrinsic motivation, driven by external rewards such as grades or exam performance, influenced how some students approached TBL. Students with lower intrinsic motivation were less likely to engage actively in TBL, especially given its low-stakes, formative structure. Some felt that since TBL activities did not directly impact their exam performance, they lacked relevance \u0026ndash; making the sessions feel more like a task to complete than a meaningful learning opportunity for them.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Even though we need to talk through the concepts and make connections in order to learn the concepts, not everybody cares to put all the energy and time to engage in a team discussion which is not really going to help their grade in the unit exams.\u0026rdquo; [AQ5]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The assessment is over material that will never be on our exams and therefore is not relevant to us. This turns TBLs into a nuisance, and more of a \u0026lsquo;task to complete\u0026rsquo;.\u0026rdquo; [BQ4]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4. Attitudes Toward Active Learning\u003c/h2\u003e\u003cp\u003eThe final factor that influenced students\u0026rsquo; experiences with TBL in our study was their general attitude toward active learning. These attitudes were shaped by their prior educational experiences, personal beliefs about how human learning occurs, and perceptions of how relevant and effective the active learning strategies were in supporting their understanding of the subject matter.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eStudents who embraced active learning\u003c/h2\u003e\u003cp\u003eStudents who were open to interactive, discussion-based formats reported stronger engagement, deeper understanding, and better retention. Even those who faced challenges, such as needing accommodations, expressed a willingness to adapt and engage meaningfully in the process when they recognized the value of active learning.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I like the opportunity to work with my classmates to see how each of us interpreted the material. Many times, I have an idea on how I think something works, and once I hear someone else's interpretation of the notes, it broadens my perspective.\u0026rdquo; [BQ2]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Solving problems in a cooperative way so everyone gets to learn from each other instead of from instructors only.\u0026rdquo; [BQ6]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I get accommodation, but there is no accommodation with TBL. And so, when it comes to processing and listening, and being able to look stuff up at the same time, I struggle with everybody talking ... and to be able to also contribute, I actually have to process that information... We did a good job, but that for me, like, it's a little stressful. So, I want to make sure that I'm giving it my best.\u0026rdquo; [BF10]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStudents who resisted active learning\u003c/h2\u003e\u003cp\u003eStudents who preferred traditional lecture-based approaches often struggled with the self-directed nature of TBL expressed discomfort with its active learning demands. Some resisted the format altogether, voicing concerns about the lack of direct instruction and requesting more structured, lecture-style support such as recorded lectures and follow-up presentations to be made available to them. This resistance highlighted a preference for passive learning and difficulty adjusting to the autonomy and collaborative expectations of team-based learning.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Prepare not to rely on the teachers. In the TBL format you\u0026rsquo;re pretty much on your own to teach yourself the whole course. There is no actual teaching of the material.\u0026rdquo; [AQ3]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It takes too much time to learn something completely on your own, besides, you may mis-learn things when there are no lectures.\u0026rdquo; [AQ4]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Science is a structured discipline, and presenting classes in a way that lacks structure is infuriating. The TBLs aren't set up to learn.\u0026rdquo; [BQ4]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eStudents who were resistant to active learning tended to remain passive or disengaged during sessions. Their disengagement often stemmed from a belief that the format did not align with their preferred learning style or that their contributions were unnecessary, especially when more vocal team members dominated the discussions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I personally am a visual and auditory learner. Sometimes I misunderstand concepts and spend way too much time seeking clarification.\u0026rdquo; [AF7]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I'm just saying like... if you always just pass the mic, then somebody who is good at it, they will always pick up and explain, and then everybody else don\u0026rsquo;t even need to worry.\u0026rdquo; [BF5]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study explored students\u0026rsquo; perceptions and experiences of Team-Based Learning (TBL) in a graduate-level histology course, yielding insights that underscore both the transformative potential and nuanced challenges of implementing TBL in biomedical education. By applying a critical constructivist lens, we were able to foreground the voices of learners and highlight the dynamic interplay between pedagogical design and student agency.\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eTBL as a Catalyst for Self-Regulated Learning and Professional Readiness\u003c/h2\u003e\u003cp\u003eOne of the most salient findings in this study was the role of TBL in cultivating self-regulated learning skills. Students who engaged with the material in advance reported a more rewarding experience. This aligns with Zimmerman\u0026rsquo;s model of self-regulation, which emphasizes the cyclical interplay of forethought, performance, and self-reflection (Zimmerman, 2000). These students described how the structure of weekly TBL sessions encouraged consistent study habits and deeper conceptual understanding, echoing prior research advocating for active learning formats as vehicles for sustained engagement and long-term retention (Crowe et al., 2008; Michaelsen \u0026amp; Sweet, 2004).\u003c/p\u003e\u003cp\u003eMoreover, many students perceived TBL as effective preparation for their future clinical practice. The need to apply knowledge under time constraints, collaborate with peers, and adapt to diverse communication styles was seen as an authentic rehearsal of the professional competencies required in healthcare settings. These findings align with the broader literature suggesting that cooperative learning not only supports academic achievement but also promotes professional development and enhanced readiness for real-world problem-solving and collaborative practice (Johnson et al., 2007; Burgess et al., 2020; Vasan et al., 2009). In addition to promoting professional competencies, TBL fosters learning through social interaction, reflecting constructivist principles that emphasize knowledge construction through dialogue and collaboration (Vygotsky, 1994). Working in diverse teams exposes students to differing perspectives and problem-solving strategies, which in turn challenges assumptions, stimulates critical thinking, and enhances cognitive integration.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eThe Dual Edge of Team Dynamics\u003c/h2\u003e\u003cp\u003eThe study also illuminated the complexity of group-based learning. The phrase spoken by one of the participants \u0026ldquo;\u003cem\u003enot all teammates are created equal\u003c/em\u003e\u0026rdquo; indirectly highlights the varying levels of student motivation to engage with the team and self-regulated learning. While some students thrived on the camaraderie, shared responsibility, and dialogic knowledge-building afforded by the team setting, others struggled with unequal participation and mismatched motivation levels. This tension underscores the importance of intentional team formation, clear role expectations, and conflict resolution strategies as highlighted in earlier TBL literature (Oakley et al., 2004; Gabelica et al., 2022).\u003c/p\u003e\u003cp\u003eInterestingly, intrinsic motivation emerged as a moderating factor in group dynamics within students\u0026rsquo; TBL experiences. Those who were driven by personal or professional goals found value in the format and thus tended to engage more actively. They often contributed more meaningfully, took initiative during discussions, and overall supported peer learning. Students who lacked intrinsic motivation expressed frustration or disengagement, subsequently leading to minimal contributions to the group and a less positive experience overall. These findings resonate with Dweck\u0026rsquo;s (1986) and Bandura\u0026rsquo;s (1997) work on motivation and self-efficacy, reinforcing the need for instructors to foster not only knowledge acquisition but also motivational and affective dimensions of learning. These motivational dynamics are consistent with broader theoretical distinctions between intrinsic and extrinsic motivation. Intrinsically motivated students often engage with tasks for enjoyment or curiosity, leading to more positive group interactions, while extrinsically motivated individuals may simply participate to avoid negative consequences or secure rewards (Maehr \u0026amp; Meyer, 1997; Graham \u0026amp; Weiner, 1996; Kolencik, 2014; Kohn, 1999). This distinction affects the quality of engagement and the ability of students to become self-directed learners, an essential skill for success in team-based learning (Bandura, 1977; Zimmerman, 2014).\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eResistance to Active Learning: A Pedagogical Barrier\u003c/h2\u003e\u003cp\u003eAnother theme that surfaced was resistance to active learning. Students with strong preferences for passive learning modalities (e.g., lectures, structured content delivery) were less likely to embrace the cognitive and social demands of TBL. This resistance often stemmed from discomfort with ambiguity, a lack of confidence in peer-led discussions, misalignment with prior educational experiences, or a discomfort with the weight of responsibility the learner feels to teach themselves in preparation for the TBL sessions. Similar resistance patterns have been reported in literature examining transitions from traditional to active pedagogies (Vasan et al., 2009; Haidet et al., 2012). This points to a broader pedagogical challenge: the need to scaffold the transition from passive into active learning, especially for students with limited exposure to such formats. Providing preparatory resources, clear rationale for the TBL structure, and early peer support may ease the adjustment and reduce initial friction (Clark et al., 2008; Freire, 2000).\u003c/p\u003e\u003cp\u003eIndeed, when students are unfamiliar with self-directed learning, the experience can be disorienting. Freire\u0026rsquo;s (1970, 2000) critique of the \"banking model\", where students passively receive knowledge from instructors, helps contextualize this discomfort. In contrast, TBL reflects a \"problem-posing\" approach, positioning students as co-creators of knowledge through active participation and dialogue. This learner-centered model fosters critical thinking, collaboration, and deeper cognitive engagement (Kincheloe, 2005). To ease the transition for students \u0026ndash; many of whom may be unfamiliar the active learning demands of the TBL structure, which is grounded in a constructivist learning paradigm \u0026ndash; transparent communication about the goals and structure of TBL format is essential. When students understand the instructional logic behind a new format, they are more likely to engage productively with it (Schwarz, 2013).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eImplications for Practice\u003c/h2\u003e\u003cp\u003eThe findings of this study have several practical implications. First, designing TBL sessions that integrate formative assessment and collaborative learning can foster deeper engagement, provided students are adequately supported and prepared. Second, ongoing instructor involvement through feedback, regular check-ins, and attentiveness to student concerns can help alleviate both interpersonal difficulties and the cognitive demands of grappling with complex material in team-based environments. Finally, integrating student voices into the evaluation and iterative refinement of TBL structures is essential. As this study shows, students offer critical insights into what works, what doesn\u0026rsquo;t, and why \u0026ndash; insights that are often overlooked in more traditional top-down educational designs.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e\u003cp\u003eDespite its many benefits, our study was limited to a single institution and a specific course, which may restrict the generalizability of findings. While qualitative depth was prioritized here, future research could triangulate these findings with quantitative data (e.g., academic outcomes, performance metrics) across multiple institutions. Additionally, exploring faculty perceptions and institutional constraints would offer a more holistic view of TBL implementation in graduate and medical education. Future investigations might also expand to include diverse student populations across undergraduate and professional programs, thereby improving the transferability and contextual relevance of findings. Employing thick description and multi-site comparisons could enhance the external validity of future research and foster best practices across settings.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study highlights the potential of Team-Based Learning (TBL) to enhance active engagement, self-regulated learning, and collaborative problem-solving in biomedical education. Grounded in constructivist learning theory, TBL supports students in integrating new knowledge through collaborative learning while developing some of the essential competencies required in professional practice, such as communication, critical thinking, and teamwork. However, the effectiveness of TBL is influenced by several factors, including student motivation, team dynamics, and prior exposure to active learning methodologies. To better navigate these challenges and maximize the impact of TBL, thoughtful design, clear guidance from instructors, and strong institutional support are critical. A well-organized and supportive learning environment ensures that students can fully engage with the TBL process and realize its potential benefits. When implemented effectively, TBL offers a meaningful and transformative learning experience that not only enhances academic outcomes but also prepares students for the complex and collaborative demands of healthcare professions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003e\u003cb\u003eEthics approval and consent to participate\u003c/b\u003e:\u003c/h2\u003e\u003cp\u003eAll procedures performed in this study have been performed following the Declaration of Helsinki. This study was reviewed and granted the \u0026ldquo;exempt\u0026rdquo; status by the Institutional Review Board (IRB) at Indiana University (protocol # 1709463378). All participants involved in the study were invited to participate voluntarily. The need for written informed consent to participate was waived by the IRB.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cb\u003eConsent for publication\u003c/b\u003e:\u003c/strong\u003e\u003cp\u003eNo copyright figures, tables, or data collection instruments in the manuscript have been used. All work is original and therefore no permissions need to be obtained.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHA designed the study and collected the data. HA, YM, HM, and RL conducted the initial data analysis. CN, DB and SH drafted the manuscript. HA supervised data analysis and manuscript preparation. All authors interpreted the results, provided feedback on earlier drafts, read and approved the final manuscript and agreed to submit it to the journal.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe wish to thank James Brokaw, PhD, MPH, and Kyle Robertson, PhD, for reading the earlier drafts of this manuscript and providing constructive feedback. We also acknowledge the Research Scholar Program at the College of Science and Technology, Temple University, for supporting the involvement of undergraduate mentees who served as research assistants in this study. In particular, we thank Sulaiman Sharief for his contributions to data processing and organization.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e\u003cp\u003eMajority of data generated and analyzed during this study are included in this published article. Complete raw datasets generated in this study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAnfara, V. A., \u0026amp; Mertz, N. T. (Eds.). (2015). \u003cem\u003eTheoretical frameworks in qualitative research\u003c/em\u003e (2nd ed.). SAGE Publications.\u003c/li\u003e\n\u003cli\u003eBandura, A. (1977). Self-efficacy: Toward a unifying theory of behavior change. \u003cem\u003ePsychological Review, 84\u003c/em\u003e(2), 191\u0026ndash;215.\u003c/li\u003e\n\u003cli\u003eBandura, A. (1997). \u003cem\u003eSelf-efficacy: The exercise of control\u003c/em\u003e. W. H. Freeman.\u003c/li\u003e\n\u003cli\u003eBonner, D., \u0026amp; Kovach, J. V. (1996). 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Routledge.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Team-based learning, biomedical education, health sciences education, self-regulated learning, constructivist learning. ","lastPublishedDoi":"10.21203/rs.3.rs-6658854/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6658854/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Traditional didactic methods in health sciences education are increasingly being replaced with active learning strategies such as Team-Based Learning (TBL), which fosters engagement through collaboration, knowledge application, and peer interaction. This study provides practical insights for educators aiming to integrate TBL into biomedical basic science courses, focusing on student feedback and perceptions about TBL format in one graduate-level histology course.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Study participants included students from two separate offerings of the same graduate histology course (Cohort A: n = 28; Cohort B: n = 27). All students enrolled were invited to participate in the study by completing a questionnaire and/or participating in a focus group. Eleven students completed the questionnaire (5 from Cohort A; 6 from Cohort B), and 18 participated in the focus groups (7 from Cohort A; 11 from Cohort B). Qualitative data were analyzed using an abductive approach, incorporating frame and taxonomic analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Four key themes emerged as conditions influencing students’ engagement with TBL: (1) preparation and self-regulated learning, (2) understanding and valuing teamwork, (3) student motivation, and (4) attitudes toward active learning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Grounded in constructivist learning theory, TBL can offer a transformative educational experience by promoting self-regulation, collaboration, and deeper engagement. However, its success depends on factors such as student readiness, team cohesion, and prior exposure to active learning, which underscores the need for deliberate instructional design, explicit student orientation, and consistent faculty facilitation to ensure effective implementation.\u003c/p\u003e","manuscriptTitle":"From Resistance to Engagement: Factors That Influence Student Outcomes in Team-Based Learning","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-10 06:00:09","doi":"10.21203/rs.3.rs-6658854/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0935b89a-8fb9-471d-8648-5a727e63b21f","owner":[],"postedDate":"July 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-07T16:08:37+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-10 06:00:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6658854","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6658854","identity":"rs-6658854","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}