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Abstract

Objective

The education of basic sciences in Pakistan encounters various problems, such as large classroom sizes, insufficient faculty, and a lack of institutional resources. These limitations have fostered a dependence on passive, lecture-centric pedagogies, leading to diminished student engagement and critical analysis. Similar tendencies are observed worldwide in resource-limited higher education settings. Therefore, this study aims to investigate the justification and feasibility of implementing team-based learning (TBL) in basic sciences education in Pakistan, utilising global literature to evaluate its adaptability, relevance, and efficacy in similar educational contexts.

Methods

A literature-based methodology was utilised, referencing 29 peer-reviewed publications from databases such as MEDLINE, PubMed, ERIC, Scopus, and Web of Science. Studies were chosen with a modified PEOT (Population, Exposure, Outcome, Type of study) framework and subjected to thematic analysis. The Confidence in the Evidence from Reviews of Qualitative Research (CERQual) and the Kirkpatrick New World Model (KNWM) were employed to assess confidence in findings and educational effects.

Results

Two analytical themes emerged: (1) TBL as a facilitator of active and collaborative learning, and (2) its function in augmenting critical thinking and knowledge application. High confidence substantiated TBL's efficacy in enhancing engagement, collaboration, and profound learning. Moderate confidence was attributed to themes related to implementation issues in resource-limited environments.

Conclusion

TBL offers a feasible educational solution for tackling systemic difficulties in Pakistan. Through adequate faculty training, curricular alignment, and gradual implementation, TBL can markedly improve the quality and efficacy of basic sciences education in the country.

Keywords

team-based learning (TBL)Pakistan basic sciences resource-constrained settings passive learning

Introduction

Basic sciences education in Pakistan, as in many resource-limited countries, encounters persistent pedagogical and institutional obstacles that constrain the quality of education and teaching. The issues include large classroom sizes and a shortage of qualified instructors, which obstruct opportunities for engagement, formative evaluation, and individualised feedback.¹ The primary reliance on didactic, lecture-based teaching methods promotes rote memorisation and hinders the cultivation of critical thinking and problem-solving abilities.^2,3 Curricular frameworks in fields such as physiology are predominantly antiquated, exhibiting minimal incorporation of active learning methodologies and insufficient congruence with modern healthcare requirements.⁴ Similar obstacles are observed in other contexts where higher education institutions encounter rising enrollment, limited faculty resources, and a demand for pedagogical innovation.^5,6 These structural challenges profoundly affect student engagement, understanding, and their capacity to apply information beyond assessments. In fields like physiology that necessitate conceptual integration, problem-solving, and clinical applicability, conventional approaches have become progressively insufficient.^1–6

Despite ongoing attempts to improve instructional quality, the predominant dependence on passive learning techniques, rote memorisation, and teacher-centered approaches have resulted in students being disengaged, unmotivated, and inadequately equipped for advanced cognitive tasks and multidisciplinary teamwork.^7,8 This study originated from a commitment to evidence-based teaching approaches and a desire to develop scalable, context-sensitive solutions to persistent gaps. This search led to the emergence of team-based learning (TBL) as a pedagogical approach capable of transforming basic sciences education in Pakistan.

TBL is a systematic, active learning approach that prioritises student responsibility, peer cooperation, pre-class readiness, and the practical application of information to real-world issues, attributes that strongly correspond with the requirements of big classes and resource-constrained environments. Worldwide, TBL has shown helpful in increasing engagement, fostering teamwork, improving knowledge retention, and developing critical thinking, especially in health professions education.^5,^9–11 Nonetheless, despite its efficacy in medical education, its application in basic sciences education fields such as physiology is still underrepresented in Pakistan and globally.^5,6,^12–14 This indicates a notable gap in pedagogical innovation, particularly given that the framework and requirements of basic scientific courses frequently resemble those of clinical fields, yet rarely receive equivalent pedagogical enhancement or institutional backing.¹⁵

The incorporation of TBL in these circumstances could alleviate several limitations concurrently, especially related to large classroom sizes and limited faculty availability. The planned phases, preparation, readiness assurance process (RAP) and application, can facilitate profound learning while enabling educators to efficiently manage large classroom sizes.^16,17 TBL promotes peer instruction and collective accountability, particularly in settings with insufficient faculty-to-student ratios.¹⁸ Furthermore, it is intrinsically flexible, allowing for localised adjustments that correspond with cultural norms, curricular development, and institutional capabilities. Although literature provides substantial evidence for the effectiveness of TBL, there is a paucity of empirical research on how these strengths translate into worldwide basic sciences education, including Pakistan.⁹ This gap does not suggest that TBL's core benefits are inapplicable; rather, it underscores the importance of examining how they can be adapted and sustained within Pakistan's unique institutional and cultural context.

The principal research question of this study is: How can TBL be adapted and implemented in basic science education in Pakistan to improve critical thinking, collaborative learning, and knowledge acquisition? This literature-based study seeks to furnish educators, curriculum designers, and policy-makers with pragmatic insights and evidence-based recommendations for the improvement of existing teaching practices in basic sciences education. This study promotes a pedagogical transformation that integrates global best practices with local contexts, facilitating deeper learning, alleviating instructional demands, and enabling students to excel in their academic and professional pursuits. The paper seeks to justify the deployment of TBL in Pakistan and presents a conceptual framework for its contextualised use, namely in the realm of physiology education.

Methodology

This study employed a structured literature-based review using systematic search and selection methods to discover and assess the available peer-reviewed literature on TBL implementation, acknowledging the deficiency of empirical research pertinent to the Pakistani context. A total of 29 peer-reviewed studies met the eligibility criteria and were included in the final synthesis, which constitutes the sample size of this review. This study was conducted between July 2024 and December 2024. The research is grounded in the philosophical framework of positivism, seeking to derive objective findings using a systematic and replicable literature analysis procedure. Although aspects of systematic review methodology such as predefined inclusion criteria, quality appraisal, and several PRISMA 2020 recommendations were implemented to ensure rigour, repeatability, and comprehensive coverage, this study was designed as a structured literature-based review rather than a full systematic review. Therefore, dual screening and registration in PROSPERO/INPLASY were not undertaken, and the review does not constitute a complete systematic review. The reporting of this study was informed by the PRISMA 2020 statement^19,20 (see PRISMA_2020_checklist).

Inclusion Criteria

The research adapted the PEOT (Population, Exposure, Outcome, Type of study design) framework to assess eligibility.²¹ The criteria were as follows: (i) Population: Undergraduate or postgraduate students enrolled in basic sciences or health professions education programmes. Both levels were included because the structural and pedagogical challenges motivating this review like large class sizes, limited faculty resources, didactic teaching culture are common to both contexts in Pakistan. While learner maturity may differ, the fundamental processes of TBL (pre-class preparation, accountability, teamwork, and application) are applicable at both levels. (ii) Exposure: Studies that documented the implementation or evaluation of TBL as a principal pedagogical approach, incorporating core components such as pre-class preparation, readiness assurance tests (individual Readiness Assurance Test (iRAT) and team Readiness Assurance Test (tRAT)), and application-oriented exercises. (iii) Outcome: Studies reporting empirical evidence on outcomes including critical thinking, knowledge acquisition, student engagement, teamwork, or implementation challenges. (iv) Contextual similarity: To ensure relevance to Pakistan, studies were included if they were conducted in, or explicitly described conditions analogous to, the Pakistani educational environment. “Analogous” was defined not solely by geography or World Bank economic classification, but by the presence of at least one of the following: large class sizes with high faculty-to-student ratios, resource-constrained institutional settings like limited faculty training, infrastructure, or teaching materials, predominantly didactic, lecture-based pedagogies, and curricular and assessment practices emphasising rote memorisation over critical thinking or application. These thresholds allowed for the inclusion of studies from South Asia, the Middle East, and other low- and middle-income countries, where such educational features frequently mirror those in Pakistan, while studies from high-income countries were included only if they explicitly described comparable structural or pedagogical constraints. (v) Type of study design: A broad range of empirical designs such as quasi-experimental, cross-sectional, mixed-methods, qualitative were accepted to capture the multidimensional effects of TBL. In addition, narrative or conceptual reviews were included where they contributed substantial insights into TBL implementation. The robustness of findings was balanced by applying design-appropriate quality appraisal tools: the Mixed Methods Appraisal Tool (MMAT) for empirical studies and the Scale for the Assessment of Narrative Review Articles (SANRA) for narrative reviews. This PEOT framework approach was chosen to adapt the commonly used PICO model (Population, Intervention, Comparison, Outcome),²² often applied in effectiveness studies. However, PICO was not appropriate for this study as there is no established standard or comparator for TBL in basic sciences education in Pakistan. Instead, the term ‘Exposure’ was deemed more relevant than ‘Intervention’ as it better captures formal and informal experiences of TBL implementation. This aligns with the broader scope of TBL as an educational strategy discussed earlier.

Independent verification and bias reduction: Although this was a single-author review, the selection and screening of studies were not conducted in isolation. To minimise bias and strengthen reliability, the search strategy was optimised and the comprehensiveness of retrieved studies was validated by a university librarian, and inclusion/exclusion decisions were overseen by the academic mentor. These safeguards are explicitly acknowledged in the Acknowledgements section.

Exclusion Criteria

Studies were excluded if they met one or more of the following conditions: Exclusively theoretical papers – Articles that discussed TBL conceptually without presenting empirical evidence (e.g., no reported student outcomes, perceptions, or implementation results). Alternative educational domains – Research conducted outside the scope of basic sciences or health professions education (e.g., humanities, social sciences, engineering), as these contexts were not directly comparable to the aims of this review. Primary/secondary education (K-12) – Studies focused on school-level teaching, which were excluded due to their limited relevance to higher education pedagogies. Borderline or mixed-context studies – When studies combined TBL with other pedagogical approaches (e.g., PBL, case-based learning) or spanned multiple disciplines, they were not automatically excluded. Instead, their eligibility was determined based on whether they reported empirical outcomes directly attributable to TBL within basic sciences or health professions education. If such outcomes were present, the study was retained.

Time Frame

The search was confined to literature published from 2001 onwards, corresponding to the period when TBL began to gain substantial prominence in health professions education.²³ This time span was chosen to ensure the incorporation of literature that represents modern instructional methodologies, specifically emphasising learner-centred pedagogies.

Sources for Literature Search

The search method was meticulously devised to obtain pertinent material from international contexts that may be relevant to the Pakistani educational setting. Prominent academic databases were chosen for this purpose, including MEDLINE, PubMed, ERIC, Scopus, and Web of Science. These databases were selected for their recognised significance in medical, educational, and health professions research. The automated searches offered a systematic expedient method for retrieving many potentially relevant studies for this literature review. Given that a sole author executed this work, automated searches provided an equitable approach to acquiring a comprehensive dataset while optimising the time and resources necessary for review. Additionally, supplementary search methods were also employed to ensure comprehensiveness. Reference lists of relevant articles were screened for potential inclusion, and grey literature, such as conference, abstracts and institutional reports, were explored to reduce the risk of publication bias.²¹ Dissertations, conference proceedings, and institutional reports were sought to include unpublished or lesser-known research that could contribute important insights. Contact was attempted with TBL researchers for unpublished studies or conference abstracts; however, no new data were obtained. While the grey literature did not yield new studies for data extraction, the attempts to include it aimed to mitigate publication bias. Although this review was conducted by a single author, safeguards were implemented to reduce the risk of bias. Dr Rebecca Williams (supervisor) oversaw inclusion and exclusion decisions, particularly for borderline cases, and Ms. Mary Ann Hilliar (librarian) validated the search strategy and assessed its comprehensiveness. These measures enhanced transparency and minimised the likelihood of missed studies.

Search Strategies, Screening, and Data Extraction

Boolean operators and MeSH terms were utilised to construct exact search strings. Keywords encompassed combinations such as “Team-Based Learning” OR “TBL,” with “Basic Sciences Education,” “Physiology,” “Medical Education,” and broader regional descriptors including “South Asia,” “Middle East,” “Developing Countries,” and “Pakistan.” To mitigate the risk of missing studies indexed under country-specific descriptors, the search strategy was enhanced by manually reviewing the reference lists of the included studies. The filtering and selection of references proceeded in three stages. First, titles and abstracts retrieved from database searches were reviewed against the inclusion criteria and irrelevant studies were excluded. Second, the full texts of the remaining references to ensure they provided empirical data on TBL's outcomes in basic sciences and health professions education. Finally, duplicate records were removed to streamline the dataset. A detailed visual representation of this selection process is shown in the PRISMA flow chart.¹⁹ Although duplicates were flagged during the initial search process, they were formally removed at the final stage. This deliberate choice was made to ensure that no potentially relevant record was inadvertently excluded prematurely, given that overlapping entries across multiple databases sometimes contained minor variations in metadata. Final removal at the end of the screening process allowed for cross-checking and verification of these entries, thereby ensuring accuracy while maintaining thoroughness.

A standardised data extraction framework was employed, following the guidelines of Bettany-Saltikov and McSherry.²¹ The extracted data include bibliographic information, study objectives, methodological design, participant characteristics (population and sample), specifics of TBL implementation, outcome measures, analytical methods, and key findings and conclusions. Following the pilot implementation of the extraction form with two studies, it was revised to incorporate more details pertinent to the research questions. The Kirkpatrick Evaluation Model was utilised to comprehensively assess the educational impact of TBL.^24,25 For this review, outcomes were operationally mapped to the Kirkpatrick New World Model (KNWM) using the following criteria: (i) Reaction (Level 1): student satisfaction, attitudes, or perceptions of TBL; (ii) Learning (Level 2): demonstrated knowledge acquisition, comprehension, or improvement in assessment performance; (iii) Behaviour (Level 3): evidence of application of knowledge, teamwork, or critical thinking skills in academic or professional tasks; and (iv) Results (Level 4): broader institutional or programme-level outcomes, such as curricular reform, faculty adoption, or sustained changes in teaching practice. Coding and mapping decisions were developed by the author with supervisory oversight to ensure consistency and minimise subjectivity. This updated model was selected for its adaptability in educational settings, facilitating the classification of results based on the depth and scope of TBL's impact. This approach enabled a detailed integration of evidence about the impact of TBL on student satisfaction, knowledge acquisition, behavioural application, and institutional transformation. Further, data saturation was achieved in this review, as the systematic search and predefined eligibility criteria ensured that no additional eligible studies or novel themes emerged beyond those included.

Quality Appraisal Criteria

MMAT was utilised for empirical investigations encompassing quantitative, qualitative, and mixed-methods research. SANRA was employed for narrative or conceptual reviews. These instruments evaluated factors including the clarity of research questions, suitability of study design, data gathering techniques, and coherence between findings and conclusions. Instead of dismissing research based on appraisal scores, quality assessments were employed to assign weight to the trustworthiness of findings during synthesis.^26,27 Studies were not omitted only based on quality assessment; rather, the robustness of each study's contribution was evaluated during the synthesis of data and the rating of confidence in results. This methodology ensured that the studies in the review were sufficiently rigorous to substantiate the study's conclusions.

Thematic Synthesis

Thematic synthesis was used as the principal method for analysing the retrieved data, adhering to the model established by Thomas and Harden (2008).²⁸ This method facilitated the synthesis of qualitative and quantitative results into cohesive descriptive and analytical themes. The synthesis process occurred in three phases: initial line-by-line coding of textual data, formulation of descriptive themes from repeating patterns, and abstraction into higher-order analytical themes that aligned with the research objectives. Given that this was a single-author review, explicit reflexivity procedures were built into the analysis to minimise interpretive bias, as advised by Braun and Clarke (2013).²⁹ These included: Iterative coding and memoing: preliminary codes were revisited multiple times, with analytic memos used to document decision-making and ensure transparency. Supervisory oversight: emerging codes, descriptive themes, and final analytical themes were reviewed with the supervisor, who provided external feedback to challenge assumptions and confirm alignment with the data. Constant comparison: coding decisions and emerging themes were repeatedly checked against the dataset to ensure that interpretations remained grounded in the evidence. These structured reflexivity steps enhanced the reliability of the thematic synthesis and reduced the risk of researcher subjectivity influencing the final analytical themes.

Evaluation of Confidence

The study utilised the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to evaluate the robustness of each theme.³⁰ This model assesses confidence based on four principal dimensions: methodological limitations, relevance, coherence, and data adequacy. Each descriptive theme received a confidence level (high, moderate, low, or very low), which guided the robustness of findings derived from the evidence.

Statistical Analysis

No formal statistical analysis was performed, as this study is a structured literature-based review rather than a primary empirical study. Instead, the analysis relied on systematic evaluation and thematic synthesis. The MMAT and SANRA were utilised to evaluate the methodological quality of the included research. To assess the educational outcomes, findings were aligned with the KNWM, facilitating categorisation into four levels: reaction, learning, behaviour, and results. Descriptive synthesis was employed to integrate evidence from the 29 included studies, emphasising recurring patterns, strengths, and gaps pertinent to the application of TBL in basic sciences education.

Results

A total of 1210 references were ascertained. Following the elimination of duplicate entries and the application of predetermined criteria for relevance, 856 records were evaluated based on their titles and abstracts. Of these, 772 were excluded for failing to align with the study's parameters. Seventy-four full-text publications were evaluated for eligibility, and 29 studies were finally incorporated into the final synthesis, as outlined in the PRISMA flow chart,¹⁹ illustrated in Figure 1.

Figure 1.

Flow Diagram Explaining Filtering of References, Adapted From PRISMA 2020.¹⁹

Appendix I in the supplementary materials presents the details of data extraction. An extensive analysis of 29 research papers from both worldwide and regional contexts with socio-educational similarities to Pakistan identified two primary analytical themes. The themes included: (1) TBL as a Catalyst for Active and Collaborative Learning, underscores the structured environment of TBL, which fosters engagement through RAPs, collaborative problem-solving, and peer accountability and (2) Enhancing Knowledge and Critical Thinking through Structured TBL Approaches, highlights how TBL promotes knowledge retention and the development of higher-order cognitive skills, such as critical analysis and problem-solving, by bridging theoretical concepts with practical applications. Each analytical theme was further supported by multiple descriptive themes. The CERQual framework was utilised to assess the strength and dependability of each finding (see Appendix II in the supplementary materials).

Analytical Theme 1: TBL as a Catalyst for Active and Collaborative Learning

This theme highlights TBL's capacity to promote active student engagement and enable significant collaboration among learners.^16,31 This analytical theme emerged from the influence of three descriptive themes: structured learning processes to enhance collaboration and engagement, fostering team accountability and interpersonal skills, and interactive and adaptable approaches to meet diverse learning needs.

Descriptive Theme 1: The Structured Learning Processes to Promote Collaboration and Engagement

An often-cited benefit of TBL is its meticulously organised framework, which inherently fosters learner accountability and engagement. The RAP, consisting of individual Readiness Assurance Test (iRAT) and team Readiness Assurance Test (tRAT), established a framework that motivated students to prepare before class and engage in collaborative activities. Numerous studies have recorded enhancements in student readiness, engagement in the classroom, and favourable attitudes towards personal accountability in learning.^14,32 Prompt feedback throughout the tRAT phase reinforced accurate comprehension and rectified misconceptions in real time, hence enhancing conceptual clarity.^33–38 The confidence in this finding was assessed as high, based on a comprehensive analysis of the evidence using the CERQual framework. The studies supporting this finding employed a range of robust methodologies, including quasi-experimental designs, cross-sectional surveys, and descriptive analyses.

Descriptive Theme 2: Fostering Team Accountability and Interpersonal Skills

Research indicated that, in addition to material mastery, TBL facilitated the enhancement of non-cognitive skills, including teamwork, communication, and conflict resolution. Students were mandated to negotiate, deliberate, and reach choices together, thereby cultivating interpersonal skills essential in healthcare and scientific domains. The team environment fostered accountability both to oneself and to colleagues. Studies from various contexts indicated that students exhibited an enhanced desire to participate in discussions, offer constructive comments, and assist in achieving team learning objectives.^{12,14,32–41} The confidence in this finding is rated as high, supported by a substantial number of well-conducted studies that collectively illustrate the role of TBL in fostering team accountability and interpersonal skills.

Descriptive Theme 3: Interactive Learning to Address Diverse Learning Needs

TBL cultivates an inclusive educational atmosphere by accommodating students with diverse academic readiness, cognitive capacities, and learning styles. The organised and interactive design, which includes readiness assurance assessments, real-life application scenarios, and team-based activities, facilitates significant engagement with content and connects theory to practice. Numerous studies confirm TBL's versatility in accommodating various learner requirements.^42,43 Obad et al. (2016) and Persky and Pollack (2011) established that structured modules and clinical application tasks catered to varying cognitive capacities and academic backgrounds.^33,34 Gopalan et al. (2013) showed that iterative methods such as iRAT and tRAT improve active engagement and foster student confidence.³² A diverse team composition enhances cognitive engagement. Research conducted by Simonson (2014) and Teixeira et al. (2019) demonstrated that collaborative problem-solving fostered perspective-taking and inclusive discourse.^36,38 Govindarajan and Rajaragupathy (2021) and Du and Yang (2017) demonstrated that the shift from conventional laboratory sessions to TBL enhanced both engagement and knowledge application.³⁵ Chen et al. (2018) documented substantial improvements in learning outcomes across 13 trials,⁴¹ whereas Ahmed et al. (2022) and Mansoor et al. (2019) emphasised the efficacy of TBL in modular medical education in Pakistan.^12,14 Subsequent research, notably by Leupen et al. (2020) and Nayak et al. (2020), underscored the significance of higher-order application tasks and systematic preparedness processes in heterogeneous classrooms.^37,40 TBL's interactive pedagogy embraces learning diversity, fostering fairness and inclusivity across multiple disciplines and delivery modalities. The confidence in this finding is deemed high, bolstered by substantial data from multiple contributory studies, characterised by large sample sizes, varied educational contexts, and rigorous methodologies.

Analytical Theme 2: Enhancing Knowledge and Critical Thinking Through Structured TBL Approaches

This theme emphasises TBL's ability to facilitate profound learning, encourage conceptual cohesion, and improve critical thinking, especially pertinent in basic fields such as physiology, where comprehension is frequently disjointed under conventional pedagogical approaches. The efficacy of TBL in augmenting knowledge and critical thinking is substantiated by three descriptive themes. The methodical incorporation of pre-class preparation and readiness assurance tests (iRAT and tRAT) provides a fundamental comprehension of key topics, equipping learners for advanced application and synthesis. Secondly, collaborative problem-solving assignments and case-based exercises aid learners in critically analysing and applying their knowledge to real-world situations, hence fostering higher-order cognitive engagement. Third, continual feedback mechanisms integrated into TBL procedures promote reflective thinking and iterative enhancement, essential for cultivating analytical skills.

Descriptive Theme 1: Improved Knowledge Retention and Application Through Case-Based Learning

Multiple studies provide evidence that students participating in TBL demonstrate enhanced knowledge retention and improved application of theoretical concepts to clinical or contextual problems.^12,31–33^,35,41,44 This was primarily due to the active learning processes inherent in TBL, specifically application exercises that necessitated students to synthesise, analyse, and evaluate real-world scenarios. Persky and Pollack (2011) and Simonson (2014) demonstrated that TBL students excelled in assessments necessitating higher-order thinking compared to their peers.^34,36 The collaborative format effectively addresses gaps in individual understanding, particularly in large cohorts with diverse academic preparedness. Ahmed et al. (2022) demonstrated that TBL sessions incorporating local healthcare challenges enhanced engagement and comprehension among medical students.¹⁴ Fatmi et al. (2013) highlighted that situating case-based discussions within the socio-cultural contexts of Pakistani students facilitated a stronger engagement with the material, thereby improving long-term retention and application.²³ Nayak et al. (2020) observed that TBL sessions in resource-limited settings, particularly in large classrooms, effectively promoted collaborative problem-solving skills and reinforced foundational knowledge.³⁷ The alignment of theoretical instruction with practical application enhances learners’ ability to apply classroom knowledge to real-world problem-solving. The confidence in this finding is high, supported by substantial evidence from multiple studies across various contexts and educational settings.

Descriptive Theme 2: Development of Higher-Order Thinking and Problem-Solving Skills

TBL's focus on critical thinking was evident in multiple studies that assessed performance according to Bloom's higher cognitive domains. In the application phase of TBL sessions, students were tasked with evaluating possibilities, justifying their judgements, and negotiating with colleagues, thereby cultivating abilities vital for clinical reasoning and scientific investigation.^32–35^,37,38,40 Burgess et al. (2017) and Mansoor et al. (2019) observed that students engaged in TBL exhibited substantial improvement in analytical reasoning, decision-making under duress, and the synthesis of intricate knowledge.^12,45 Ahmed et al. (2022) validated these findings, highlighting that TBL's emphasis on iterative learning and practical applications corresponds effectively with contemporary curricular requirements in Pakistan, cultivating skills essential for clinical and professional practice.¹⁴ Zeb et al. (2022) evidenced substantial enhancements in students’ critical thinking facets, including analytical reasoning and problem-solving, via TBL techniques.³⁹ The confidence in this finding is assessed as high, bolstered by a considerable body of data from several studies conducted across diverse educational contexts and disciplines, including physiology, medical education, and pathology.

Descriptive Theme 3: Addressing Implementation Barriers in Low-Resource Settings

Although TBL offers various pedagogical benefits, its application in varied educational environments, particularly those with low resources, presents several problems that require strategic solutions to enhance its efficacy. Primary concerns encompass technological adaptability, logistical limitations, faculty opposition, and maintaining equitable student engagement. Research by Govindarajan and Rajaragupathy (2021) and Carbrey et al. (2015) emphasised challenges in maintaining learner engagement in virtual and hybrid TBL settings^42,46 These problems highlight the necessity for a resilient technological infrastructure, organised facilitator assistance, and engaging digital platforms. Kibble et al. (2016) and Nayak et al. (2020) identified logistical challenges that include the management of large class sizes, restricted session durations, and diverse learner groups.^37,44 Effective solutions encompassed faculty training, advanced session planning, and organised group formats. Ensuring student accountability has also become a significant issue. Research conducted by Simonson (2014) and Gopalan et al. (2013) highlighted that student contributions in team environments are not uniform.^32,36 Structured peer assessments and well-delineated team roles were proposed as methods to enhance equity and involvement. Cultural inertia and institutional constraints in Pakistan exacerbate the challenges of TBL adoption. Resistance from students and faculty, as documented by Mansoor et al. (2019) and Ahmed et al. (2022), underscores the necessity of gradual deployment, tailored case materials, and robust administrative backing.^12,14 Utilising adaptive group composition and additional resources to accommodate diverse learner preparation can enhance the efficacy of TBL.^38,40 Through strategic planning and local adaptation, these obstacles can be converted into possibilities for sustained educational innovation.¹⁸ The confidence in this finding is assessed as moderate, bolstered by a significant number of research studies examining implementation issues in various educational contexts.

These findings highlight TBL's flexibility and significance in improving the quality of teaching and learning in basic sciences education. By synchronising instructional methodologies with modern educational theory and practical requirements, TBL offers a feasible solution to numerous systemic issues within the Pakistani context.

Discussion

This literature-based study examined the feasibility of applying TBL in basic sciences education in Pakistan, characterised by large classrooms, constrained staff resources, and a primarily passive learning culture. The results, derived from 29 studies across pertinent global and regional contexts, demonstrated a robust evidence foundation affirming the educational efficacy of TBL, especially in augmenting student engagement, critical thinking, and knowledge application. This debate seeks to contextualise these findings within the Pakistani educational framework and emphasise the benefits and problems associated with the broader use of TBL.

TBL as a Pedagogical Fit for Pakistan's Educational Challenges

This research reveals a distinct correlation between the structural advantages of TBL and the systemic deficiencies of Pakistan's existing educational framework, especially in the basic sciences. The conventional lecture-based method, still prevalent at numerous institutions, provides restricted opportunities for active engagement, formative evaluation, or cooperative learning. Conversely, TBL intrinsically fosters preparation, accountability, and collaboration, attributes that are deficient yet critically required in local classrooms. The examined research indicates that TBL is most effective in environments with large class sizes and limited resources, both of which are characteristic of Pakistani institutions. The organised readiness assurance method and peer-based applications offer a scalable framework for extensive groups, ensuring student involvement without necessitating a proportional rise in instructional personnel. These characteristics indicate that TBL may provide a viable remedy for faculty shortages and the constraints of unidirectional instructional methods, rendering it particularly appropriate for fields such as physiology, where conceptual depth and applied reasoning are crucial. Moreover, the collaborative essence of TBL contests the hierarchical teacher–student dynamic frequently observed in South Asian classrooms. By allocating responsibility among students, TBL promotes autonomy and participation while quietly altering the power dynamics in the classroom, facilitating a more student-centred learning environment. TBL facilitates both a pedagogical and cultural transformation, fostering more inclusive, discussion-oriented educational methodologies.

Enhancing Learning Outcomes Through Critical Thinking and Knowledge Application

A notable finding from the synthesis is TBL's ability to improve higher-order cognitive skills. The Pakistani education system primarily focuses on subject coverage and examination results, but TBL shifts the learning process towards critical thinking, problem-solving, and practical application. This examination of studies frequently indicated enhancements in students’ skills to analyse, evaluate, and apply knowledge, particularly when learning activities were structured around contextualised scenarios or clinical situations. This is especially significant in physiology education, where comprehension necessitates not merely memorisation but also the integration of systems and their application in clinical practice. The case-based, decision-oriented framework of TBL effectively facilitates this form of learning and reflects the analytical thinking anticipated in medical and allied health fields. Through the promotion of student engagement with intricate problems in collaborative environments, TBL enhances comprehension of physiological principles and fosters transferable skills, including communication, bargaining, and decision-making amidst ambiguity. Moreover, the collaborative environment aids in alleviating gaps in prior knowledge and academic readiness, prevalent issues in Pakistani classrooms, by enabling students to assist and learn from each other. These peer interactions foster a social learning environment that enhances individual accountability and fosters knowledge of the subject.

Contextual Challenges and Implementation Considerations

Notwithstanding its numerous benefits, the execution of TBL in Pakistan faces certain challenges. Numerous studies observed opposition from both professors and students, especially during the initial phases of implementation. Educators may perceive the preparation and reorganisation of course materials as onerous, while students habituated to passive learning may first experience apprehension regarding the expectations imposed upon them in collaborative environments. International experiences indicate that focused faculty development programs and staggered implementations can effectively mitigate such issues. Institutions offering training workshops, orientation sessions, and peer mentorship for faculty members experienced elevated acceptance rates and more seamless incorporation of TBL methods. Moreover, customised TBL materials, adapted to the local curriculum and assessment standards, can facilitate the transfer for both educators and learners. Infrastructure continues to be a significant challenge. Classroom layouts, often meant for lecture-based training, may require modification to facilitate team setups. However, innovative strategies like rotating team configurations, staggered session timetables, or digital collaboration platforms can alleviate these limitations, particularly in resource-constrained settings.

Implications for Policy and Curriculum Development

The results of this study have significant consequences for educational policy and curriculum development. The incorporation of TBL should be prioritised in curriculum reform initiatives, especially within the Higher Education Commission's aim for enhancing quality in science education. Secondly, educational institutions must allocate resources for faculty training programs that facilitate the transition from content delivery to facilitation. Thirdly, interdepartmental and interinstitutional collaboration can facilitate the creation of a shared repository of context-specific TBL resources, alleviating the strain on individual educators. Moreover, curricular innovation must be accompanied by supportive assessment methodologies. The efficacy of TBL is contingent upon its connection with course objectives and assessment methodologies. Conventional examinations that assess rote memorisation may diminish the competencies developed through TBL. Consequently, assessment reform, integrating formative evaluation, peer review, and application-oriented tasks, is crucial for maximising the advantages of this model.

Proposed Curriculum Model for Implementing TBL in Physiology Education

This paper proposes a contextualised curricular approach to facilitate the efficient application of TBL in basic sciences education in Pakistan, specifically emphasising physiology. The model employs Kern's Six-Step Curriculum Development Framework, offering a systematic methodology for curriculum design that includes needs analysis, instructional planning, implementation, and evaluation.^47,48 This decision was shaped by the model's versatility across many fields and educational environments, as well as its focus on aligning competencies with systemic educational and healthcare requirements. This model employs six sequential steps: problem identification, targeted needs assessment, goal setting, educational strategies, implementation, and evaluation, ensuring that the development and integration of TBL are systematic and aligned with the primary objectives of enhancing student engagement, critical thinking, and collaborative learning (Table 1).

Table 1.

Integration of Kern's Curriculum Model as Adapted for TBL in the Basic Sciences Education Context of Pakistan.

Steps	Action	Focus	Themes addressed
Problem Identification and General Needs Assessment	Assess challenges in traditional teaching methods in Pakistan, emphasising limitations in critical thinking and collaboration.	Identify the gaps in existing teaching strategies and the potential of TBL to address these, particularly in improving knowledge retention, teamwork, and problem-solving skills.	Descriptive Themes 1 and 6: Highlights the need for structured processes to foster active and collaborative learning. Emphasises identifying and addressing challenges in traditional teaching methods.
Targeted Needs Assessment	Evaluate learner and educator needs through surveys and interviews.	Assess student exposure to active learning and faculty readiness to transition from didactic to interactive teaching. Focus on tailored training and resource allocation.	Descriptive Themes 2 and 3: Focuses on understanding diverse learners and educators needs for successful TBL adoption. Ensures the readiness of stakeholders to engage in team-based and interactive approaches.
Goals and Objectives	Establish clear and measurable objectives for TBL implementation.	Enhance active learning, develop critical thinking, promote teamwork, and ensure faculty readiness. Align objectives with Bloom's taxonomy.	Descriptive Theme 5: Establishes objectives to promote critical thinking and analytical skills.
Educational Strategies	Develop structured pre-class preparation, in-class application exercises, and peer evaluations.	Leverage constructivist principles, immediate feedback, and contextual adaptations like culturally relevant case studies. Emphasise scaffolding and guided learning.	Descriptive Themes 4 and 1: Focuses on strategies to enhance knowledge application through contextual exercises. Ensures structured activities to support engagement and collaboration.
Implementation	Conduct a phased pilot program with small student cohorts and trained faculty.	Replace selected lecture sessions with TBL modules. Gather iterative feedback to refine the framework before scaling. Collaborate with institutions for broader adoption.	Descriptive Themes 6 and 2: Uses a phased approach to refine and optimise TBL implementation. Ensures team dynamics are addressed and improved during the pilot phases.
Evaluation and Feedback	Use mixed methods to assess the impact on learners and facilitators.	Implement pre- and post-session quizzes, reflective exercises, and qualitative feedback to gauge effectiveness and sustainability. Conduct follow-ups for long-term impact.	Descriptive themes 5 and 6: Evaluate the long-term effectiveness of TBL in addressing educational challenges. Monitors the impact of TBL on fostering critical and analytical thinking skills.

Step 1: Problem Identification and General Needs Assessment

Pakistan's education in basic sciences encounters substantial pedagogical obstacles, such as large classroom sizes, insufficient active learning, and restricted staff capabilities. These systemic challenges impede the advancement of higher-order thinking and student involvement.⁴⁹ TBL is recognised as an effective approach that facilitates organised, cooperative, and practical learning, effectively meeting the educational requirements of physiology students.⁵⁰

Step 2: Targeted Needs Assessment

A targeted needs assessment revealed deficiencies in teacher preparedness and infrastructural constraints. It underscored the significance of teacher development programs and incremental institutional modifications to meet the logistical requirements of TBL, including classroom arrangement and access to pertinent resources.

Step 3: Goals and Objectives

The curriculum seeks to: Augment critical thinking and collaborative learning; Foster student engagement via structured participation; Advocate for the practical application of theoretical knowledge; Develop teacher proficiency in active learning approaches. These aims are aligned with Bloom's Taxonomy to ensure thorough cognitive development.

Step 4: Educational Strategies

The fundamental components of TBL constitute the instructional strategy, comprising: pre-class preparatory assignments; individual and team Readiness Assurance Tests (iRAT and tRAT); application-oriented group tasks; and peer evaluation systems. These elements are augmented by culturally pertinent case studies and contextually tailored content to ensure relevance.

Step 5: Implementation Plan

A gradual strategy is advised, commencing with pilot modules in designated physiology courses. Faculty members ought to receive training via workshops and be supported during their initial implementation. Consistent feedback mechanisms between instructors and students will facilitate continuous improvement.

Step 6: Evaluation and Feedback

Evaluation must encompass both formative and summative approaches, employing: pre- and post-assessments of learning outcomes; student satisfaction surveys; and faculty feedback with reflective practices. A mixed-methods evaluation will assess both immediate effectiveness and enduring impact.

This model offers a systematic, evidence-based framework for incorporating TBL into the physiology curriculum and can act as a basis for wider application in other basic science fields.

Conclusion

This study aimed to investigate the potential and justification for the implementation of TBL in basic sciences education in Pakistan, utilising worldwide evidence to evaluate its relevance and practicality. The results demonstrate that TBL provides a strong, organised, and student-centred alternative to conventional lecture-based teaching. Through the promotion of accountability, teamwork, and application-oriented learning, TBL effectively tackles numerous systemic difficulties inherent in the Pakistani setting, including large classroom sizes, insufficient faculty resources, and passive learning cultures. Two primary analytical themes arose through thematic synthesis. The initial demonstration showcased TBL's ability to convert learning environments into more interactive and collaborative settings, hence improving student engagement and interpersonal skills. The second emphasised TBL's function in promoting profound conceptual comprehension and critical thinking abilities vital in the sciences, yet sometimes inadequately cultivated due to rote-based curriculum. These advantages were demonstrated to be especially pertinent in fields like physiology, where the synthesis and application of information are crucial for educational and professional achievement. Notwithstanding its potential, the execution of TBL necessitates meticulous planning and contextual customisation. Anticipate and overcome faculty resistance, infrastructural limitations, and student unfamiliarity with active learning. Institutional support, systematic orientation for educators and learners, and gradual piloting are essential for successful integration. Furthermore, integrating assessment methodologies with the learning objectives of TBL is crucial to establish consistency between teaching and evaluation.

Recommendations

This review's findings yield numerous crucial recommendations for the effective implementation of TBL in basic sciences education in Pakistan. Initially, universities should commence small-scale pilot implementations of TBL in undergraduate physiology or other basic science courses. This method would facilitate the accumulation of localised evidence and the incremental enhancement of practices before widespread institutional implementation. Secondly, faculty development must be prioritised. Targeted training workshops, peer mentorship, and professional development sessions can assist educators in transitioning from traditional lecturing to the facilitative roles necessitated by TBL. Insufficient planning and support may impede successful integration due to faculty reluctance. Thirdly, TBL activities must be meticulously aligned with established course learning outcomes and incrementally integrated into curricular reform initiatives. This will ensure alignment between pedagogical approaches and educational goals, hence improving student learning and institutional endorsement. Fourth, assessment procedures must be modified to align with the principles and learning outcomes advocated by TBL. Priority should be given to instruments that assess collaboration, analytical reasoning, and practical knowledge, rather than depending exclusively on evaluations based on rote memorisation. Ultimately, additional research is required to investigate the long-term effects of TBL within the Pakistani setting. Longitudinal studies conducted across various institutions can provide significant insights into the impact of TBL on academic performance, student engagement, teacher satisfaction, and overarching institutional change over time. These guidelines seek to facilitate a significant transition towards skills-based, student-centred learning in Pakistan's basic sciences education by contextualising global research and presenting a structured path for localised implementation.

Limitations

This study provides a thorough synthesis of the current literature on TBL in basic sciences education; however, certain limitations must be recognised. It solely depends on secondary data and excludes primary contributions from students or instructors in Pakistan. The meticulous selection of literature from comparable contexts is undermined by the lack of locally created data, which restricts the specificity and transferability of the results. The generalisability of the findings is limited by differences in study methods, sample sizes, and institutional contexts. The majority of the studies examined were centred on medical or health professions education, predominantly within clinical disciplines, while a smaller number concentrated only on basic sciences like physiology or biochemistry. Consequently, certain extrapolations to non-clinical contexts should be approached with caution. A formal sample size calculation was not conducted, as this is a literature-based review. The sample size was determined based on the number of studies that fulfilled the predetermined eligibility criteria (n = 29). While this represents the best available evidence, it may also constrain the statistical generalisability of the results. The inclusion of both undergraduate and postgraduate studies enriched the synthesis but it could introduce variability; future research should explore level-specific dynamics of TBL more explicitly.

Another limitation stems from the absence of full inter-rater coding and dual assessment during data extraction and quality appraisal. Although supervisory oversight and librarian support helped ensure consistency and minimise bias, the reliance on a single author means that some subjectivity may have influenced coding, outcome categorisation, and quality ratings. Similarly, while reflexivity procedures were integrated into the thematic synthesis such as memoing, constant comparison, supervisory review, the absence of dual coding may have introduced interpretive bias. Moreover, the examined studies primarily concentrated on short-term outcomes such as student satisfaction and academic achievement. The long-term implications, including alterations in learning behaviour, retention, or institutional reform, were infrequently discussed. Ultimately, although appraisal instruments like CERQual and MMAT were employed to mitigate bias, a degree of subjectivity persists in judging the applicability of international findings to Pakistan's distinct educational situation. A final limitation is the relatively small pool of directly relevant literature. This reflects the paucity of empirical studies on TBL in basic sciences education within comparable contexts, rather than a restrictive search strategy. Although this constrained the breadth of evidence, the systematic search, rigorous appraisal, and in-depth thematic synthesis ensure that the findings remain robust and contextually meaningful. Future research based on local pilot studies, larger samples, dual-coded syntheses, and longitudinal data is necessary to corroborate these findings.

Supplemental Material

sj-docx-1-mde-10.1177_23821205251389360 - Supplemental material for Implementing Team-Based Learning in Basic Sciences Education in Pakistan: A Contextual Rationale for Low-Resource Settings

Supplemental material, sj-docx-1-mde-10.1177_23821205251389360 for Implementing Team-Based Learning in Basic Sciences Education in Pakistan: A Contextual Rationale for Low-Resource Settings by Aliya Maqsood in Journal of Medical Education and Curricular Development

Supplemental Material

sj-docx-2-mde-10.1177_23821205251389360 - Supplemental material for Implementing Team-Based Learning in Basic Sciences Education in Pakistan: A Contextual Rationale for Low-Resource Settings

Supplemental material, sj-docx-2-mde-10.1177_23821205251389360 for Implementing Team-Based Learning in Basic Sciences Education in Pakistan: A Contextual Rationale for Low-Resource Settings by Aliya Maqsood in Journal of Medical Education and Curricular Development

Footnotes

Acknowledgements

I would like to express my profound gratitude to my supervisor, Dr Rebecca Williams, for her guidance and oversight during this study, particularly in refining the inclusion criteria and verifying the screening of eligible studies. I also extend my thanks to Ms. Mary Ann Hilliar, University Librarian, for her expert support in optimising the database search strategies and validating the comprehensiveness of retrieved studies. Their contributions helped to ensure methodological rigour, minimise bias, and strengthen the reliability of the review process.

ORCID iD

Aliya Maqsood

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data used or analysed are available within the manuscript.

Supplemental Material

Supplemental material for this article is available online.

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