Nursing students are expected to be active learners capable of recognizing and constructing knowledge collaboratively. If they can acquire knowledge more autonomously, teachers can spend less time transferring knowledge unilaterally and improve their performance in clinical practice and theory classes [1, 2]. As such, team-based learning (TBL) is a group teaching strategy that has recently gained popularity nationally and internationally . Group learning is defined as the process of mutual learning in which participants freely share ideas, feelings, and attitudes about a particular topic, resulting in knowledge growth and attitude change .
Collaboration in healthcare is crucial; it refers to professionals taking on complementary roles and sharing responsibility for problem solving, decision making, and implementation of patient-care plans. TBL is seen as one way to equip healthcare professionals with the teamwork and communication abilities they need to broaden and strengthen each team member’s knowledge and skills in a collaborative manner and to build a team community [5-7].
Professor Larry Michaelsen developed TBL at the University of Oklahoma in the late 1970s [8, 9]. It adopts a collaborative team approach to traditional classroom teaching and incorporates problem-based learning (PBL) to promote active problem solving in a team. It involves collaborative learning and two-way knowledge transfer between teachers and students divided into small groups in a large class setting where teachers and students collaborate to achieve curriculum goals with clear learning objectives [8, 10]. The teacher assists and enables students to work in teams to enhance knowledge development, skills, and attitudes, thereby improving their teamwork and increasing individual participation.
TBL be used in classrooms in conjunction with structured topic-oriented activities to enable students to delve deeper into the content and to easily understand how to apply their learning, thereby improving academic performance while increasing learner responsibility and satisfaction [3, 11]. It comprises a variety of learning strategies to enhance learning participation such as student team-achievement division (STAD), team game tournaments (TGT), the jigsaw puzzle method, team-accelerated instruction, cooperative integrated reading and composition, learning together, and group investigation [9, 12]. The TGT method involves creating a lively and engaging tournament-like atmosphere to stimulate team progress, which is ideal for teaching in scenarios where there are single and objective answers with clear definitions. This method can boost student motivation and promote their growth through their competitiveness in group learning, as well as increase their active participation [9, 13].
Both decisive thoughts and actions are competencies required during the nursing process, which must be cultivated over the course of nursing education , since professional competency is essential to earning the trust of patients whom nursing students are expected to care for in clinical practice. In addition to these competencies, other nursing skills such as how to provide safe care are also taught in schools through classroom demonstrations in simulated hospital settings [15-17]. Currently, most nursing students learn all this through demonstrations and video presentations from the faculty and self-managed group-studies and simulations. Since good nursing requires a combination of theoretical knowledge and practical skills, it is common for students to follow a step-by-step process before repeating the actions independently. Therefore, Johnson and Johnson  and Lin  claimed that interaction and discussion among team members, shared responsibility for success and failure, assessment, and an atmosphere of inter-team competition can help enhance learning effectiveness.
While there have been numerous studies on the application of TGT in physical education in Taiwan and internationally [13, 20, 21], no study has focused on its use in the education of nursing competencies. Therefore, in the present study, this study aimed to examine the theoretical background of the TGT approach and formulate a systematic set of teaching strategies and cooperative group learning activities based on the TGT approach in the context of nursing education.
What Is Nursing Competencies Education?
Nursing students must know how to collaborate with others, a skill they can develop through interpersonal experiences. General clinical nursing competencies refer to professional knowledge—basic medical knowledge, knowledge of various diseases, and nursing care, which are all holistic and integrated concepts. Presenting case studies and developing skill-based activities on various health-related factors and issues can effectively enhance students’ ability to perform nursing tasks in clinical practice . Thus, nursing competencies can be defined as the students’ ability to develop the necessary skills and to expand their professional knowledge. Demonstrating this knowledge through their acquired skills is highly valued. As such, the ability to integrate it into clinical practice has always been a necessary component of nursing education.
In the nursing field, summative assessments are often utilized to examine learning activity components and the functioning of others, as well as to assess the extent to which goals are met to evaluate the effectiveness of students’ technical learning. Currently, most schools employ checklists or rating scales to assess the skills of their students [15, 17]. Students also conduct an objective structured clinical examination (OSCE) and mini-clinical evaluation exercise (mini-CEX) before graduation to evaluate the depth and proficiency of the students’ clinical nursing skills [22, 23].
The Royal College of Physicians pioneered the use of the direct observation of procedural skills (DOPS) method to assess trainees’ clinical skills, which include their relevant knowledge, abilities, proficiency, communication skills, and patient care/professionalism . The structured and columnar scales used to construct the technical assessment checklist, OSCE, or mini-CEX all incorporate the DOPS method to directly observe and assess the actual operational details. It uses the structured scales formed by simple operational technical assessment items and teacher feedback to evaluate students’ overall performance [24-26].
Theoretical Framework of the TGT Method
The four basic elements key to the successful implementation of the TBL approach are teams, accountability, feedback, and assignment design. Students must organize and manage their teams effectively, be responsible for the quality and quantity of individual work and teamwork, and seek frequent and immediate feedback, all while engaging in quality teamwork and the interactive process to promote learning and team growth . The TGT method—which is based on the TBL approach—was created by DeVries and Slavin in 1975, in which students are divided into teams and assigned tournament tables to heterogeneously group different abilities and homogeneously learn similar ones .
The TGT method is a cooperative learning method that provides opportunities to develop team interaction and collaboration skills, sets achievement goals in the classroom, and empowers students with face-to-face collaboration across teams, thus, enhancing their sense of achievement, engagement, and motivation [18, 28, 29]. Slavin and his team were inspired by the works of Vygotsky and Piaget to refine collaborative learning, while designing activity processes . As such, Slavin et al.  built their work and started using motivation, social cohesion, cognitive development, and cognitive refinement as four theoretical directions to achieve positive cooperative learning effects in 1976. Students must cognitively refine existing concepts in a non-monolithic way .
There is limited research on this teaching method globally, as well as in Taiwan. In one such study on the method, Chien et al.  found that students were exposed to an information-integrated curriculum, and they were able to explore different avenues to deepen and broaden their existing knowledge. They found this learning method enjoyable, lively, interesting, and helpful in understanding the text. This in turn enhanced their learning interest and enabled them to complete meaningful online courses. Those who would normally drop courses like English, mathematics, anatomy, and physiology after experiencing difficulties discovered that a competitive yet enjoyable approach boosted their motivation to participate in the course, their insight and sensitivity, and their tolerance of their teammates, even if their progress was somewhat limited [31-33].
Studies on activities formulated to develop specific skills have also indicated that a tournament-centric curriculum is effective in enhancing competencies such as skill proficiency, useful learning, peer interaction, cooperative/social behaviors, games/joint activities, trust/respect, and intimate/positive relationships . It can also help reduce conflict and aggressive interpersonal interactions . Although the skill level of students cannot be fully reflected in the teaching, teachers must nonetheless enhance their learning motivation by teaching the relevant rules, knowledge, and skills. They must also promote the team members’ interest in participation and ensure that there is sufficient time for skill practice .
In the heterogeneous grouping and homogeneous competition method, both high and low achievers are coached and mentored. Furthermore, both sides are encouraged to communicate, think, accept the opinions of others, and motivate each other to enhance interpersonal interactions and develop critical thinking skills [13, 20, 21, 34]. The abovementioned studies suggest that competitive contexts can stimulate students’ motivation to learn, improve their academic performance, and enhance learning effectiveness for various difficult courses and skills.
TGT Method Composition and Principles
With a learning-based education concept that considers students’ individual learning and develops cooperation and interaction among them, the cooperative learning composition and principles according to Slavin  are as follows:
Class presentations begin with a lesson demonstration and explanation. This method emphasizes group discussion with a focus on its manner and process.
Four- to five-member teams are deemed ideal. They can be formed with either of the following criteria in mind: major courses, minor courses, academic achievement, grade level, cultural background, gender, personality traits, skill and expertise, familiarity with the subject, and learning motivation with regards to peer learning and teamwork. When students bring diverse perspectives to the activity, their desire to achieve a consensus will be conducive to a cooperative performance .
The questions in the game are designed based on the data of the presented activity to test each team member.
The process must emphasize cooperation, team achievement, and a competition with a point system. It covers:
- A series of carefully designed arrangements, learning groups, subject competitions, team awards, and transfers or impacts.
- At the beginning of the course, the teacher informs all the students that cooperative learning of TGT will be implemented, and the students are instructed to form teams and move toward the competition table.
- The table setup is announced to the students at the start of the tournament. The activity is a competition on the table between students of comparable ability from different teams.
- The winning and losing teams are revealed to facilitate evaluation.
- Competitors are divided into teams according to their ability, with those of comparable ability competing to learn cognitive and affective skills, as well as the value of competitive sports, together.