Healthcare professionals, particularly paramedics, are continually engaged in educating patients, their families, students, other healthcare professionals and the wider community (Edwards, 2011). As a direct result of this shift in focus, there is now greater emphasis on healthcare professional students to obtain a level of proficiency in teaching during their tertiary education (Hudson and Tonkin, 2008). Peer-assisted learning (PAL) allows senior students to assist their junior peers through teaching, learning support and small group conversations. PAL also provides the potential benefit of additional educational discussion which may not occur in the presence of an academic or tutor (Weyrich et al, 2009).
In recent times, there has been a paradigmatic shift in higher education towards a greater emphasis on ‘learning’ rather than ‘teaching’. A greater degree of focus is now placed on the construction and maintenance of high quality, learner-centred environments, with PAL being seen as a crucial component to these learning environments (Hudson and Tonkin, 2008). Other examples include scenario-based learning, and patient-centred learning, both of which provide capacity for PAL opportunities. PAL is also perceived as an option to continue providing interaction-rich learning environments in the face of reduced resources and continual increases in student numbers, through the sharing of experiences from senior peer-tutors to junior tutees. PAL provides a number of advantages over academic-led learning, such as enhanced peer-to-peer relationships, as peers are perceived to be more approachable than academic staff (Hudson and Tonkin, 2008; Christiansen and Bell, 2010).
What does the literature say?
The national and international literature is largely supportive of PAL across different education sectors (K-12 to tertiary education) and educational programmes and professions. The literature focuses peer-teaching confidence, acquisition of skills, and satisfaction of peer teachers and peer learners (Secomb, 2008).
In a study of German medical students by Rengier et al, peer-learners stated that having a peer teach them greatly improved their confidence when performing a variety of medical imaging interpretations (Rengier et al, 2010). Similarly, students reported a more relaxed and safe learning environment and felt their peers were more approachable than their lecturers. This was supported by students claiming their knowledge was enhanced by their greater willingness to ask questions and make mistakes in front of their peer tutors (Yates et al, 1997; Glynn et al, 2006).
A number of papers have examined PAL and peer-learners’ acquisition of skills. For example, a study by Graziano found that third-year medical students performed better in skill examinations when taught by fourth year student peers compared to obstetric and gynaecology residents (intervention group n=32 and control n=28, respectively) (Graziano, 2011). The peer-teachers did not receive any formal teaching instruction, but did attend a 30-minute orientation before each day to emphasise the key objectives. Overall, the peer-learners performed more surgical skill steps correctly than their resident-led counterparts (16.1 versus 14.4 of 22 total steps assessed, p <0.01) as assessed by a skill examination. Significant differences between the two groups were seen in several skills: marking of the surgical site (p = 0.02), positioning of equipment (p = 0.01) and sterile hand washing technique (p = 0.01), with the PAL group out-performing the resident-led group in each instance.
Weyrich et al used a randomised control study to test skill performance between PAL students and those taught in a traditional faculty facilitated tutorial (Best et al, 2008; Weyrich et al, 2009; Hill et al, 2010; Hunt and Ellison, 2010; Ketele et al, 2010; Rengier et al, 2010). They found that there was no clinically significant difference in score between the two groups. There were also no statistically significant differences between the peer-taught and lecturer-taught groups, with results showing that both groups performed equally well in the skill performance test (4.90 ± 0.07 versus 4.71 ± 0.10 points; p = 0.11) and that peer-teachers were just as effective as faculty staff (p = [0.18–0.89]) (Weyrich et al, 2009). Overall, skill acquisition seems to require more discipline-based research in order to fully understand the role PAL can play in undergraduate paramedic education.
A number of papers address peer-teacher preparation programmes where peer-teachers are provided with ‘teaching’ or ‘facilitating’ skills. Some of the reported preparation programmes include a targeted focus on communication and interpersonal skills while others focused on increasing the knowledge of the peer-tutors on the subjects or content they were to teach (Best et al, 2008; Ketele et al, 2010; Outhred and Chester, 2010).
The ability to communicate effectively with a varying audience is one of the several critical skills that healthcare professionals are required to have. Harmer et al, in particular, found that 88% of nursing students (n=32) reported that they had increased their capacity to communicate (Harmer et al, 2011). Several studies indicated that students felt that it was easier to communicate with peers as opposed to with instructors, and that their ability to communicate had improved (Scott, 2005; Chojecki et al, 2010, Harmer et al, 2011). It was found by both Scott, and Chojecki et al, that tutees were able to have open communication with their tutors about the stresses associated with their study and were able to gain some support from their tutors (Scott, 2005; Chojecki et al, 2010). Chojecki et al also noted that instructors reported that there appeared to be an increase in the number of conversations that would not have occurred if students were participating in a discussion with an instructor (Chojecki et al, 2010).
A large body of work suggests that both peer-teachers and peer-learners are satisfied with PAL programmes. For example, students involved in a study by Nikendei et al, reported that they felt they learnt more effectively, were highly satisfied and would welcome PAL in their curriculum (Nikendei et al, 2009). Similarly, a study by Dickson et al resulted in 14 recommendations on how to improve the associated PAL programme with emphasis placed on the continuation of the programme in medical courses (Dickson et al, 2011). Likewise, research by Glynn et al, showed that students not only preferred the PAL programme to normal teaching but that they felt that the content was more relevant and interesting (Glynn et al, 2006).
Overall, the literature on PAL is promising and has been shown to increase student confidence and involvement (Secomb, 2008). This is supported by studies which have shown improved student knowledge, as a result of PAL programmes when compared to faculty run tutorials, and is also seen to improve tutor retention of material (Hudson and Tonkin, 2008; Christiansen and Bell, 2010). As a result, PAL is seen to be a beneficial approach in which to improve student satisfaction. This pilot study seeks to explore third-year students’ experiences of teaching and assessing junior students, and first-year students’ experiences of being taught and assessed by senior students.
Methodology
Design
This pilot study used a quasi-experimental design.
Participants
First and third-year students studying the undergraduate Bachelor of Emergency Health (Paramedic) (BEH-P) at Monash University were invited to participate in the study. Twenty third-year students were designated to be peer-tutors, working in randomly allocated pairs to teach groups of approximately 10 first-year students. Skills taught included patient assessment, basic life support and manual handling. Peer-tutors were assessed on their teaching abilities during the third tutorial session, as well as a written lesson plan, in place of the normal third-year assessment. Eight third-year students who chose not to participate in the peer-teaching acted as a control group. First-year students were assigned to either the control or intervention group based on timetabling allocation. There were n=87 first-year students allocated into the control group with n=40 in the intervention group. The subject matter to be covered were basic clinical skills which included CPR, blood pressure, chest auscultation, neurological assessment and the patient examination.
The third-year students (peer-tutors) received no formal training before commencing their lessons due to time constraints, but did receive a brief orientation prior to their first session. Peer-tutors were required to develop a structured lesson plan which covered their interpretation of the relevant material associated during each teaching session. The peer-tutors met with the tutees for one 2-hour tutorial session per week, over a three week period, for a total of 6 hours peer-teaching time.
Instrumentation
An investigation of peer-assisted teaching and learning was performed to ascertain the peer-tutors and tutees beliefs regarding the role of teaching in paramedic practice and confidence teaching skills after the peer-tutoring experience. These were assessed using the Peer Teaching Experience Questionnaire (PTEQ) (14 items) and the Clinical Teaching Preference Questionnaire (CTPQ) (11 items), as used by McKenna and French (McKenna and French, 2011). Both self-reporting measures used a 5-point Likert scale (1=Strongly Agree and 5=Strongly Disagree). No items are reversed scored or coded. Demographic data including previous peer teaching experience and qualifications were also collected. An open-ended comments section (with no specific questions) was also included.
Procedures
Ethics approval was granted by Monash University Human Research Ethics Committee. Explanatory statements were provided to all students at the commencement of the study. Questionnaires were distributed at the conclusion of the last teaching session to the intervention group and the peer-tutors. The remaining control students were given the questionnaire during a lecture where all first-year paramedic students were required to attend. It took approximately 10 minutes to complete the questionnaire. No incentives or follow-up was undertaken.
Data analysis
Data processing included the entry of all results into Statistical Package for the Social Sciences (SPSS) (Version 19.0). Non-parametric statistics were used since data were ordinal and data were unequal. A Mann-Whitney U Test was performed to compare between groups, genders and age. The results were considered statistically significant if the p-value was < 0.05.
Results
First-year students
A total of 127 first-year BEH-P students completed the CTPQ (92% response rate). The majority of these students were female n=82 (64.4%) and aged less than 26 years n=108 (85%). Seventy percent (n=89) had no previous experience being taught by peers. Table 1 shows the results of the CTPQ as the control group (n=87) versus the peer-assisted learning group (n=40).
| Item | Group | Md (IQR) | Sig |
|---|---|---|---|
| 1. Teaching is an important role for paramedics | Control | 2 |
0.97 |
| Intervention | 1 |
||
| 2. My peers are more supportive to me when I am performing a paramedic skill than my instructor | Control | 3 |
<0.001 |
| Intervention | 4 |
||
| 3. I am more self-confident and able to perform independently because of being taught by my peers, more so than by my instructor | Control | 3 |
<0.001 |
| Intervention | 3 |
||
| 4. I feel freer to approach my instructor for help than I do my peers | Control | 3 |
<0.001 |
| Intervention | 3 |
||
| 5. My ability to problem solve improves more from instructor teaching than from my peers | Control | 3 |
<0.001 |
| Intervention | 3 |
||
| 6. I am less anxious when performing a paramedic skill in the presence of my peers than my instructor | Control | 2 |
<0.001 |
| Intervention | 3 |
||
| 7. Being taught clinical skills by my peers increases my interaction and collaboration with other students more than when being taught by my instructor | Control | 2 |
<0.001 |
| Intervention | 2 |
||
| 8. Being taught clinical skills by my instructor increases my sense of responsibility more than being taught by my peers | Control | 2 |
<0.001 |
| Intervention | 3 |
||
| 9. I learn more from my instructor than my peers | Control | 2 |
<0.001 |
| Intervention | 3 |
||
| 10. I can communicate more freely with my peers than my instructor | Control | 2 |
<0.001 |
| Intervention | 3 |
||
| 11. The feedback I receive from my peers is from a student's viewpoint, and is therefore more honest, realistic and helpful than from my instructor | Control | 4 |
<0.001 |
| Intervention | 3 |
** Md=Median; IQR=Interquartile Range
The results show significant differences between the two groups in all items except for the first, where the majority of all first-year students felt (agree or strongly agree) that teaching is an important role for paramedics n=120 (94%). Over half n=70 (55%) agreed with the statement ‘I am less anxious when performing a paramedic skill in the presence of my peers than my instructor’. Almost two-thirds n=82 (64%) felt that being taught by peers increased their collaboration with other students compared to their instructor. More than half n=68 (53.5%) felt freer to communicate with their peers than their instructor. Students in the PAL group were more likely to feel self-confident performing skills when taught by peers, to engage in collaboration with other students and also to view feedback from peer-tutors as more honest, realistic and helpful compared to instructors, than the control group (p < 0.001).
Third-year students
Twenty-seven third-year BEH-P students completed the PTEQ (33% response rate). Nineteen of these students were peer-tutors (due to one unreturned survey), with the remaining 8 students as the control group. The majority of these students were females n=18 (66.6%) aged under 26 years n=22 (81.5%). Two-thirds of the students (n=18) had no prior experience teaching their peers. All third-year students n=27 felt that teaching is an important role for paramedics and that there should be more opportunities for peer-teaching in the curriculum. The majority of respondents n=22 (88%) agreed that paramedics have a professional responsibility to teach students and their peers. There were no statistically significant differences between the intervention and control group. Of the peer-teaching cohort, the majority n=17 (89.5%) felt comfortable teaching junior students. Most peer-teachers n=16 (84.2%) felt that they had developed the skills for teaching basic clinical skills as a result of the PAL programme. Additionally, n=17 (89.5%) felt more confident in their teaching ability after the peer-teaching experience.
An open-ended comments section was used by peer-tutors to express their general views and perceptions surrounding the PAL programme. None of the control group completed the comments section. A sample of typical responses from participants is shown:
‘Really great experience and I'm so glad I participated!’
‘Would have loved more time for each session. Feedback from students also suggests they would have liked more time too.’
‘Was a good opportunity to revise our own skills which had become a little rusty!’
‘The teaching experience was an enjoyable one. After completing sessions I feel more confident in both teaching and assessing peers as well as my own practical skills.’
‘Some teaching education prior to sessions would be beneficial.’
‘This is a trial that needs to be permanently implemented into this course. There are many third-year students who would benefit hugely from this.’
Discussion
The results of this study support the previous literature on PAL, with students being receptive to the notion of PAL. As the demand for health professionals increases, and subsequently so does the number of student health professionals, there is a growing need for better utilisation of teaching and learning resources (Hudson and Tonkin, 2008). PAL has grown in interest within the tertiary education sector in parallel with the professional standards presented by paramedic bodies expecting student competency in teaching and learning approaches. This has been noted in the field of paramedicine and was reflected in the opinions of participants of this study, with 92% agreeing that the ability to teach is an important role of paramedics.
The majority of the literature surrounding PAL shows a positive experience for both the tutors and the tutees (Glynn et al, 2006; Secomb, 2008; Nikendei et al, 2009; Hunt and Ellison, 2010; Dickson et al, 2011), and this was reflected in the results that were obtained in our pilot study. The results that we obtained from our study indicate that students feel PAL is a positive concept, with open-ended comments from third-year students (peer-teachers) stating that they would like more time to spend educating peers and that the programme should be integrated throughout the undergraduate degree. First-year students (peer-learners) also indicated that PAL was a positive experience with the majority of them saying they felt more comfortable with peers, and that they felt less anxious performing clinical skills and more supported than when educated by an instructor. This point warrants further investigation in a mixed methodological study.
Increased confidence
In line with previous studies, it was shown that there was an increased level of confidence in both the peer-teachers and peer-learners at the completion of the pilot study (Yates et al, 1997; Glynn et al, 2006; Hunt and Ellison, 2010; Rengier et al, 2010). Tutees were more likely to feel self-confident in performing clinical skills when taught by peers and more confident in participating in collaboration with fellow students. Over half of the peer-learners also agreed that they felt less anxious performing their clinical skills in front of their peers rather than their instructors. This is similar to findings found by Glynn et al (2006) and Rengier et al (2010). There was also an effect on the tutors, where 89% of participants (n=17) felt more confident in their teaching abilities after the peer-teaching experience. This is important for a number of reasons: firstly, if students have more confidence in their teaching abilities they will be more likely to take the opportunity to educate others when the opportunity presents its self (Rengier et al, 2010); second, if students have confidence in their ability to teach, there is the potential that they might be more willing to become the future educators for paramedics.
| Item | Group | Md (IQR) | Sig |
|---|---|---|---|
| 1. Teaching is an important role for paramedics | Control | 1.5 |
0.482 |
| Intervention | 1 |
||
| 2. What I have learnt in this unit will help with my graduate paramedic role | Control | 1.5 |
0.964 |
| Intervention | 1 |
||
| 3. The peer teaching experience was time and effort well spent | Control | 2 |
0.187 |
| Intervention | 1 |
||
| 4. The peer teaching experience was personally rewarding | Control | 2 |
0.106 |
| Intervention | 1 |
||
| 5. I now understand the principles underpinning teaching and learning | Control | 2.5 |
0.179 |
| Intervention | 2 |
||
| 6. I was initially apprehesive about the peer teaching requirement in the unit | Control | 4 |
0.305 |
| Intervention | 3 |
||
| 7. I felt comfortable teaching the junior students | Control | 1.5 |
0.305 |
| Intervention | 2 |
||
| 8. I have developed skills for teaching basic clinical skills | Control | 1 |
0.509 |
| Intervention | 2 |
||
| 9. The peer teaching experience allowed me to reflect on my own previous learning | Control | 1 |
0.330 |
| Intervention | 1 |
||
| 10. I enjoyed working with the junior students | Control | 1 |
0.429 |
| Intervention | 1 |
||
| 11. I felt uncomfortable assessing the junior students’ skills | Control | 2 |
0.731 |
| Intervention | 4(2–4) | ||
| 12. I would be more confident teaching a clinical skill after this experience | Control | 1.5 |
0.419 |
| Intervention | 1 |
||
| 13. There should be more opportunities for peer teaching in the curriculum | Control | 1(1–2) | 0.803 |
| Intervention | 1 |
||
| 14. Paramedics have a professional responsibility to teach students and their peers | Control | 1 |
0.202 |
| Intervention | 1 |
** Md=Median; IQR=Interquartile Range
Increased communication
Previous studies conducted by Scott (2005), Chojecki et al (2010) and Harmer et al (2011) all reported that communication skills were improved and that students felt more comfortable communicating with peers rather than instructors. Our results reflected these findings with more than half of the participating first-year students (n=68) agreeing that they felt more comfortable communicating with peers than their instructor. This supports the findings of Rengier et al, who reported a more relaxed and safe learning environment (Rengier et al, 2010). More effective communication is important in the health care setting, as it promotes a more relaxed environment for patients and clinical staff. This also has the potential to reduce medical errors through enhanced levels of communication, as a significant proportion of medical errors are linked to failures in communication (Moore et al, 2003).
Also, almost two thirds of first-year students (n=82) agreed that being taught by peers increased their collaboration with students, compared to when they are taught by an instructor. Increased communication and collaboration among peers also increases the likelihood of future PAL occurring and also increases the likelihood of learning occurring between peers (Secomb, 2008).
Previous teaching experiences and preparation programmes
Despite the fact that there is greater emphasis being placed on tertiary education students having the ability to teach clinical skills, 67% had no prior experience teaching peers. This indicates the need for preparatory training to facilitate the transition of third-year students to peer-tutors. The importance of a preparation programme (which includes teaching theories and methods, information on different teaching strategies and other useful teaching resources) is highlighted in several articles (Best et al, 2008; Ketele et al, 2010; Outhred and Chester, 2010), with focus on communication, knowledge and clinical skills. Despite this limiting factor, 89% of third-year participants felt more confident in their teaching abilities and felt comfortable teaching junior peers after the completion of the peer teaching programme.
Overall satisfaction was high, with the entire tutor cohort agreeing that there should be more opportunities in the curriculum for peer teaching in the future and that teaching is an important role for paramedics. This was supported by the finding of Dickson et al, who found that participating students recommended that PAL should continue throughout their medical education, and should not be a once off occurrence (Dickson et al, 2011). Also, none of the peer-learners reported feeling disadvantaged by being taught by peers when compared to the control group and enjoyed the experience of being taught by peers. These results are similar to Glynn et al (2006), Nikendei et al (2009) and Dickson et al (2011), who all found that students had a positive view of PAL and that it would be welcomed into the curriculum.
Limitations
This pilot study had several limitations. A lack of randomisation and unequal study groups weakens the reliability of the results, while the generalisability of our study is reduced as this study was performed at one Australian university on a single student paramedic cohort. Additionally, as the scales were self-reported there is the potential for responder bias. This is particularly possible as the third-year tutors were assessed in this trial in place of their normal assessment, and this may lead to the students believing that the PAL sessions were an easier mode of assessment.
Recommendations
Future research into the effectiveness of PAL in paramedic undergraduate studies should include the utilisation of focus groups to increase the volume and quality of data. Additionally, the recruitment of a larger peer-tutor cohort may be required to obtain data of a higher quality. The effectiveness of PAL for other health disciplines and national and international benchmarking comparisons should also be explored.
Conclusions
As found in previous studies on PAL, the results from this pilot study show that both first and third-year students are receptive to the idea of peer-assisted teaching and learning. Both student groups reported the potential benefits from a PAL model. The preliminary results from our pilot study support a larger scale study to determine if PAL should be considered for implementation into the existing paramedic curricula.