2015, 37: S33–S39
Near-peer-assisted learning (NPAL) in undergraduate medical students and their perception of having medical interns as their near peer teacher BAHAA ABA ALKHAIL King Abdulaziz University, Jeddah, Saudi Arabia
Abstract Introduction: A near-peer-assisted learning term (NPAL) is ‘‘a trainee one or more years senior to another trainee’’. The current study is aiming to determine the pattern of NPAL activities, to compare its effect on student’s course achievement score and to determine the perception of students regarding having near-peer clinical teaching from their fellow medical interns. Methods: A total of 189 third year medical students participated in the study. The study questionnaire contains three sections. The first is the focus group section, self-administered questions and lastly quality control section. Trained staff helped in conducting the data collection. Results: Clinical teaching with mentoring was experienced by 116 students (61.4%) from their assigned interns in the early clinical experience course. The results of the study showed higher course achievement grades for students who experienced mentoring with clinical teaching compared to those students who experienced mentoring only, but it did not reach statistical significance. The study also found that most medical students acknowledged and agree that their near peers medical interns could provide unique input in helping them mastering clinical and communication skills competencies, the average percent for the seven opinion questions of the response agree combined with strongly agree was 62%. Conclusion: In conclusion, third year medical students recognize the unique and important role of near peer teaching in under graduate medical education and its importance for their professional development. NPAL strategy should be encouraged and used in other medical schools. The benefits of NPAL to peer teacher and in late clinical medical years needed to be investigated in future studies.
Introduction
Practice points
Educators know that an ideal way to truly understand new material is to teach it. The use of students as peer educators provides many benefits to the student’s teacher and his or her classmates (Hartman 1990). Most medical professionals are expected to teach students as an integral part of their role as doctor, in fact ‘‘doctor’’ in Latin means ‘‘teacher’’ (Bulte et al. 2007). A near-peer teacher term is ‘‘a trainee one or more years senior to another trainee’’ and a peer-teacher is one at the same level (Bulte et al. 2007). Rodrigues et al. (2009) noted that many researchers use the terms ‘‘peer-assisted learning (PAL)’’ and ‘‘near-peer-assisted learning (NPAL)’’ interchangeably without reference to any seniority. Peer-assisted learning is an umbrella term encompassing a variety of collaborative and cooperative educational strategies, including peer teaching and learning, peer assessment, peer mentoring, and peer leadership (Aston & Molassiotis 2003; Scott 2005). Operational definitions of each specific type of
Medical students believes that their near peers can provide useful formative feedback on their clinical skills performance. Clinical skills well acquired from medical interns in a friendly environment and structured learning setting. Students believe near peer formative assessment could be fair. Introducing clinical skills teaching in early medical years is well accepted and appreciated from medical students. Near-peer teacher need to be knowledgeable and prepared to give clinical session.
PAL as in the literature are as follows: peer teaching and learning is student instructing student (Iwasiw & Goldenberg 1993); peer assessment and feedback is students evaluating other students’ products or outcomes of learning
Correspondence: Prof. Bahaa Aba Alkhail, Professor and Chairman of Family and Community Medicine Department, Faculty of Medicine, King Abdulaziz University, P.O. Box: 1374, Jeddah 21431, Saudi Arabia. Tel: +966 1 2 6060025; +966 505 682 037 (mobile); Fax: +966 1 2 6408403; E-mail: [email protected]; [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/S10033–S7 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1006602
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(Topping 1998); peer mentoring is a student relationship with another student that fosters nurturing, sharing, encouragement, and support (Glass & Walter 2000), and lastly peer leadership is students leading other students independently from the clinical instructor (Bos 1998). Researchers have suggested that PAL implemented in clinical education in order to augment and supplement the role of the clinical instructor can be intentionally planned, but regularly occurs unintentionally or incidentally (Hartman 1990; Mensch & Ennis 2002; Tolsgaard et al. 2007). Studies over the past two decades in nursing, physical therapy, and medicine document the planned and unplanned use of PAL as well as its benefits in laboratory and clinical medical education (Aston & Molassiotis 2003; Scott 2005). Research has also been conducted in these fields examining students’ preferences for PAL compared to other forms of clinical instruction (e.g., expert-led instruction) (Hartman 1990; Henning et al. 2006; Tolsgaard et al. 2007). Further rationale for peer teaching importance, and a possible explanation for the many positive outcomes is the concept described by Lockspeiser et al. (2008) named ‘‘cognitive congruence’’. Is basically the concept of sharing similar learning experience and knowledge between the peer teacher and learner due to the added close proximity in age? This allowed peer teacher to use meaningful language easily understood by their learners and given at different appropriate levels (Nestel & Kidd 2003). Leeper et al. (2007) suggest that cognitive congruence promotes student-learners feel more at ease with a peer- or near-peer teacher than with a senior clinician (Leeper et al. 2007). Peer teaching benefited peer teacher as well who can improve and consolidate their own knowledge and experience (content and process learning) (Bulte et al. 2007; Rodrigues et al. 2009). Researches regarding NPAL in clinical medical training in Arab counties are sparse. The objectives were to determine the pattern of the NPAL activities provided (mentoring only versus mentoring with clinical teaching); secondly, to compare the effect of the NPAL activities on student’s course achievement score; and lastly, to determine the perception of third year medical students regarding having near-peer clinical teaching from their fellow medical interns.
Materials and methods Study setting The ‘‘Early Clinical Experience’’ course (ECE) included 18 sessions of two hours twice weekly that spread over the first semester in the third year of medical school. The students taught history taking, physical examination, patient communication skills as well as getting acquainted with different hospital sections. Medical interns’ participation in the course was on a voluntary base and for the purpose of getting the third year students become acquainted with different hospital sections and services. Male and female third year student groups were formed during the course in the form of three students in each group, which were organized by the course instructor during the initial phase of the course and according to students’ preference. Interns were assigned to the students S34
groups of the same gender. Each medical intern practices either mentoring as part of the course objectives or mentoring plus clinical teaching in unintentional and voluntary base depending on the intern personal readiness and willingness. Giving clinical teaching by medical interns was not part of the course objectives, and was given without any prior preparation. The student’s assessment was in the form of two A-type MCQs summative written exams representing 80% of the total course marks, and a logbook representing the remaining 20%.
Study subjects, sample size and sampling technique Total population of third year medical students during the academic year 2011/2012 was 308 of which 242 participated with a returned questionnaire (118 were males and 124 females). Exclusion criteria: Students who attend the course for the second time or those who did not set for the mid or final exam were excluded. During the pilot study, two males and three females met these criteria and accordingly they were excluded.
Study design Ex-post-facto design, describing/analyzing results subsequent to knowing net outcome effect (retrospective). Ex-post-facto design is a non-experimental research technique in which preexisting groups are compared on some dependent variable; it is a type of study that can masquerade as a genuine experiment. This experiment appears to be a true experiment because of the way the groups are separated and the way the analysis is performed, but it is still subject to the same limitations as non-experimental research. The assignment of participants to the levels of the independent variable is based on events that occurred in the past; this is where the name is derived from. This non-experimental research is similar to an experiment because it compares two or more groups of individuals with similar backgrounds who were exposed to different conditions as a result of their natural histories (Lammers & Badia 2005).
Data collection methods, instrument used and measurements Instruments Questionnaire was developed for the third year medical students. The questionnaire contains three sections; the first is a focus group questions, then self-administered individual questions, and the last section, quality control section. Training in running out a focus group structured interview session was taken place to improve inter and intra-observer reliability coefficient. Before the individual interview, the structured focus group interview sessions were conducted within each male and female group. Collecting focus group response with consensus within the group that shared understanding views with interaction between them with no domination by one or two students added more valid and reliable information (data). Asking the number and duration of clinical teaching sessions after a period of two semesters and summer period may lead to recall bias that could be different between the male and the
Peer-assisted learning and its perception among medical students
female groups, but employing within group response with consensus (focus group) and controlling for gender will aid in minimizing this systemic bias. Basketball style was used where the question is asked; response is elicited, and then passed it off to another student. After the conduction of the focus group, students were asked to sit separately and answer the selfadministered questions. Variables Definition in the focus group section Type of NPAL practiced on students’ group, by asking them whether they had mentoring only or mentoring with clinical teaching from their assigned interns - Independent variable (Nominal). Seven questions assessing each students’ group experience, specific strong points, and area of improvements, with near peer clinical teaching given by their assigned interns (Nominal). Peer teaching between students (within the group) yes and no response - Confounding variable. Number of clinical teaching sessions given Confounding variable (Continuous). Average duration in minutes of clinical teaching sessions - Confounding variable (Continuous). Variables Definition in the self-administered section: Seven self-administered questions measuring student’s opinion regarding having interns giving them near peer clinical teaching or assessment with mentoring [Likert’s – five-point scale (Scored according to the following criteria: 1 ¼ strongly disagree with the statement, 2 ¼ disagree, 3 ¼ neutral, 4 ¼ agree and 5 ¼ strongly agree) (Ordinal)]. Variables Definition in the quality-control section: The questionnaire contained two contradictory questions for quality control of student’s response (Validity). Finally, the questions regarding level of completeness, the accumulative grade point average (GPA) and course achievement score. (GPA) - Confounding variable (Continuous). Then categorized to two levels 4 and 44. Course achievements score (CAS) - Dependent net outcome variable (Continuous) that was changed to binary variable, grade AþB versus CþD (Nominal).
Data management and analysis plan Data entry, cleaning, and manipulation was performed using Statistical package of Social Science (SPSS) program version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, version 20.0, Armonk, NY). Descriptive analysis using tables, graphs, and numeric presentation was used. The normally distributed continuous variable was presented in the form of mean and standard deviation, for qualitative variables median was used. Nominal variables will be presented by mode and ordinal variables by median. Bivariate analysis, using student t-test for continuous outcome with binary independent variable and chi-square test for two categorical variables. Multiple Logistic Regression was used to test hypothesis and not to predict variables, forced technique (Method: Enter in SPSS) was employed where all the variables were included in the model with course achievement score as binary outcome in two levels, grade A þ B versus C þ D categories to test the effect of NPAL alone and with its
interaction with gender using dummy variables controlling for confounding. Odds ratio (OR) and 95% confidence interval (CI) were used to assess the strength of association and its significance. All statistical tests were significant at the level of p value50.05, with two tails probability.
Pilot study A sample of 20 students from the previous academic year, 2010/2011, were selected for the pilot study. The questionnaire was checked for ambiguity of questions, mutually exclusive and singularity in responses. Time needed to complete all sections of the questionnaire as well as the level of training of assistant students on running focus group interview sessions were assessed to improve inter and intra-observer reliability measures. Testing the content validity of the questionnaire revealed clarity and no confusion from the questions asked, face validity (expert review) done by four faculties specialized in Medical Education. Reliability of the questionnaire was at Cronbach’s alpha ¼ 0.83 for all questions; Cronbac’sh alpha ¼ 0.79 for characteristics of near peer clinical teaching practices questions; and Cronbach’s alpha ¼ 0.87 for students opinion regarding having near-peer clinical teaching or assessment by interns.
Ethical considerations Using interviewed questionnaire with coded names and identification numbers. Informing the students about the purpose of the study verbally and in a written form on the cover page of the questionnaire was employed. Coding key was kept in a safe and secret place where only the investigator can access it, since the study discloses and check the level of medical intern’s professionalism and competence, but without requesting the name of the interns. Final written report of the course evaluation were shared and discussed with key stakeholders before submitting or presenting it.
Results Of the 242 third year students participated, only 189 (78.1%) completed the study questionnaire with a valid and nonmissing responses, of which 89 (49.1%) were males. Clinical teaching with monitoring was experienced by 116 students (61.4%) from their assigned interns in the early clinical experience course. Percent of male and female students experiencing clinical teaching with monitoring was similar 61.8% and 61.0%, respectively. Table 1 shows that 61.21% of students reported having 4–6 sessions during the course period and that 43.1% of these sessions were planned ahead by the medical interns (Table 2). Students’ opinion regarding having near-peer clinical teaching or assessment from their fellow medical interns is shown in Table 3. Seven opinion questions were used and coded as follows; strongly agree coded 5, agree coded 4, no opinion coded 3, disagree coded 2 and strongly disagree coded 1. Female and male students showed median opinion score of agree level regarding having different NPAL activities (Table 3). The total median score for the seven opinion questions was 26 (maximum possible score 35) and for each
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question median score of 4. The average percent for the seven questions of the response agree combined with strongly agree was 62%. The two levels of NPAL activities and student course achievement grade variables showed the same total median score of students’ opinion regarding having near-peer clinical teaching or assessment (which was 26), correspond to level agree in the five-point Likert’s scale. Students who experienced clinical teaching with monitoring had higher percent of grade A combined with grade B than those students who experienced monitoring only, 79% versus 70% (Figure 1). On the other hand, testing this relationship using independent-samples t-test showed no significant
Table 1. Near-peer clinical teaching practices given by assigned medical interns.
Variable Number of clinical teaching sessions
Duration of clinical teaching sessions (min)
Category
Frequency
Percent
1–3 4–6 46 Total 30 min 430–60 min 460 min Total
30 71 15 116 23 57 36 116
25.86 61.21 12.93 100% 19.83 49.14 31.03 100%
difference in the mean score of course achievement between these two groups. Using logistic regression analysis with course achievement score as the dependent variable categorized into two levels (grade A þ B coded 1 versus grade C þ D coded 0) and near-peer-assisted learning (NPAL) as independent variable with two levels (monitoring only coded 0 and monitoring with clinical teaching coded 1) showed no significant association, controlling for grade point average, number of clinical teaching sessions, average clinical teaching sessions duration in minutes, and gender (Table 4). No significant association was found when the interaction term of gender with NPAL was added into the model. Selection bias may have occurred having groups with high GPA students cluster together and insisting in having medical interns assigned to them practicing mentoring with clinical teaching, while other groups of students with average or low GPA tend usually to cluster together not insisting or caring for such an issue. Statistical analysis using multiple regressions did 100%
1
3
90%
21
D C B A A+
21 80% 70%
37 60% 19 50% 40%
Table 2. Third year medical student’s experience of near peer clinical teaching given by their assigned medical interns.
18
30%
38
20%
Near peer clinical teaching practices with positive response The intern plan well for the each sessions The intern is competent in providing the session (teaching, feedback, and assessment) The intern practice communicating skills with us The intern understand our needs as students The intern help me to acquire clinical skills
Frequency
Percent
50 86
43.1 74.14
10%
14
17
0% Mentoring
Mentoring with clinical
NPAL 94
81.03
72
62.07
84
72.41
Near Peer Assisted Learning
Figure 1. Near-peer associated learning (NPAL) with course achievement grade.
Table 3. The median and percent score of student’s opinion, regarding having near-peer clinical teaching or assessment by interns*.
Opinion questions Clinical teaching sessions given by the intern were satisfactory Formal assessment and feedback by the intern were satisfactory Clinical teaching knowledge given by the intern will enhance my clinical knowledge Clinical teaching skills given by the intern will enhance my clinical skills Communication skills practiced by the intern during the sessions will enhance my communication Skills Formal clinical assessment by the intern will be valuable to me Clinical skills will be acquired well from the intern than from the consultant
Male (n ¼ 89)
Female (n ¼ 100)
Total (n ¼ 189)
% Agree þ strongly agree
4 4 4
4 4 4
4 4 4
58 61 64
4 4
3.5 3
4 4
54 62
4 4
4 4
4 4
65 63
*Opinion questions coded; strongly agree coded 5, agree coded 4, no opinion coded 3, disagree coded 2, and strongly disagree coded 1.
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Peer-assisted learning and its perception among medical students
Table 4. Multiple logistic regressions for course achievement score**.
95% C.I. For (OR) Variable name NPLA^
GPA* GENDER# NCTSD
DCTS
Category Mentoring only Mentoring with clinical teaching 4 44 Male Female 1–3 4–6 46 30 min 30–60 min
p Valueþ
Odds ratio (OR)
Lower
Upper
0.8
1.0 1.54
_ 0.37
_ 6.33
0.005
1.0 4.12 1.0 0.2 1.0 0.61 0.55 1.0 1.40
_ 1.91 _ 0.09 _ 0.14 0.10 _ 0.36
_ 8.87 _ 0.47 _ 2.56 3.24 _ 5.48
0.005 0.76
0.21
(**)Outcome variable 0 ¼ grade A þ grade B (N ¼ 143), 1 ¼ grade C þ grade D (N ¼ 46). (þ)Sig. (2-tailed) t-test. (^)Near–peer-assisted learning: mentoring only ¼ 0, mentoring with clinical teaching ¼ 1. (*)Grade point average 4 ¼ 0, 44 ¼ 1. (#)Male ¼ 0, Female ¼ 1. (D)Number of clinical teaching sessions. ()Duration of clinical teaching sessions in minutes.
overcome this confounding effect by controlling for the variable GPA.
Discussion Peer-assisted learning (PAL) has been embraced by medical educationalists for many years (Hartman 1990; Aston & Molassiotis 2003; Scott 2005). In fact, the benefits of PAL have been extensively described and are reputed to positively correlate with examination performance (Aston & Molassiotis 2003; Scott 2005). Figure 1 showed that course achievement grades for students who experienced mentoring with clinical teaching was higher than in those who experienced mentoring only, but it did not show a statistical significance (Table 4). This could be due to three reasons, judging the quality of clinical teaching by third year medical student as well as the competency of medical interns in giving clinical skills sessions could have been misclassified since this was their first encountered experience with clinical teaching. In the present study, 72.41% of the student who experienced clinical teaching from the interns reported that they had peer teaching from their classmates. The 43.1% and 74.14% figures of reporting that clinical teaching sessions were planned ahead by their assigned interns and that their assigned interns were medically competent in teaching clinical skills, respectively, might have been overestimated (Table 2). Lastly, course achievement score, which is the course assessment, may not reflect clinical skills assessment since it is in the form of two written A-type MCQs exams and a logbook reflecting hospital’s observation practices only. Clinical skills acquired from the clinical skills sessions during the course could not have been assessed by the present course assessment format. The course stakeholders are revising the course study guide to incorporate more basic clinical skills using the medical school state of the art skill lab facilities. The benefits associated with PAL, however, are not confined to examination scores only. Other student benefits
recognized are those of lowering subjective distress that could occur from (Bulte et al. 2007; Silbert & Lake 2012) negative experiences during the course of clinical teaching taught by faculty teacher showing a lack of appreciation and verbal abuse. Researchers have also shown that pairing junior and senior undergraduate students establish psychological and social support system and aids professional and personal development (Scott 2005; http://www.ncbi.nlm.nih.gov/ pubmed/2252487; Iwasiw & Goldenberg 1993) as peers can prove powerful positive role models (Topping 1998). The advantages of PAL do not appear to be limited just to the peer learners; peer teacher also have been shown to benefit significantly in this learning environment (Glass & Walter 2000). In fact, in some studies, it has been shown that peer tutors appear to show significantly greater cognitive gains than their peer learner counterparts (Somervell 1993; Bos 1998; Josephson & Whelan 2002; Mensch & Ennis 2002). Nearpeer teaching during medical school appears to be an important curricular consideration; it prepares future physicians to serve as educators for both junior physicians and patients (Hartman 1990; Mahdi et al. 2013). Interaction of students with their peers in a classroom setting and attempting to answer questions from the group, peer educators may gain insight into which concepts they have a thorough understanding of and for which they need to study further. Trained student teachers can be as good as associate professors in teaching clinical skills. The present study showed that the number and duration of NPAL activities with clinical teaching were limited, since only 12.93% of all third year medical student who experienced clinical teaching had more than six clinical teaching sessions in the whole period of the course, while only 31% of them said that some of their sessions lasted more than 60 min (Table 1). Since the study was targeting the peer learner and not the peer teacher, the practice of training the interns was not investigated nor asked, although prior training and later supervising the interns are very important to
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minimize tutors’ uncertainties (Secomb 2008; Weyrich et al. 2008). The present study found that most medical students acknowledged and agree that their near peers could provide unique input in helping them mastering clinical and communication skills competencies together with comfort in feedback and assessment (Table 3). Accordingly, teaching feedback to early medical students resulted in improved skills of delivering corrective specific feedback to their fellow students, not all medical education studies supported this, some reported resistance to peer evaluation (Somervell 1993; Searby & Ewers 1997; Topping 1998), especially if these assessments are summative and composing the final grade rather than the formative one. This present study provides two new pieces of information on near peer assessment. First, medical students in KAU believe that their near peers can provide useful formative feedback on their performance; secondly, and even more important, is that students believe near peer assessment is fair. The present study had limitations; first pre-test for third year medical students was not possible since the study is retrospective, so any gain in clinical practice, if identified, could be due to previous experience in clinical practice from other courses in first and second medical years. This is less likely since the third year in the medical program in KAU is the first year for students encounter with clinical teaching, besides ECE course is the first course in the third year medical curriculum. In this study, the incomplete-questionnaires were 53 of 242 returned questionnaires or 21.9%. Data from non-participants was not available regarding their thought about NPAL and so comparison of respondents with non-responders data was not possible. Lastly, the study was conducted using a single course on third year medical students in a single medical school with a hybrid curriculum, so the results may be generalized but with caution for other settings. One goal of future research should be answering the question of how peer student teachers can benefit from their experience. Our study design only allowed us to conclude students benefited from NPAL as peer students. The NPAL process does not only include the time spent in the classroom teaching, but also the time spent preparing for the session and its benefits through reflecting upon it. Determining to what extent each of these aspects contributed to the student’s gain of knowledge are not fully investigated although its benefits to both peer student and peer student teacher is well documented (Josephson & Whelan 2002; Secomb 2008). The research findings indirectly support the recommendation that training and planning ahead for clinical teaching sessions by near peer teacher is vital, and training in feedback and assessment enhances successful implementation of a peerevaluation system (Secomb 2008). The results suggest that students’ perception of peer teaching was positive and more clinical sessions can be considered in future (Secomb 2008). Further studies are required to confirm the magnitude and benefits of NPAL in late clinical medical years rather than third year where clinical teaching is well established, its concept understood and highly practiced as part of every course study guide (Mustafa et al. 2011). S38
Conclusion and recommendation Near-peer-assisted learning strategy should be encouraged and used in undergraduate medical education throughout the medical curriculum. Third year medical students recognize the unique and important role of near peer teaching in under graduate medical education and its importance for their professional development. Further studies are needed to show the magnitude of NPAL benefits in late clinical medical years for near peer students. Readiness, organization, and competence of the near-peer teacher are essentials in the learning process; further research is needed to show the benefit of NPAL practice to the near-peer teacher. Stakeholders were feed-backed regarding study findings and instructed that planned and organized clinical skills sessions by near-peer medical interns to their fellow third year medical students should be part of the future course learning objectives.
Glossary Near-peer-assisted learning term NPAL is ‘‘a trainee one or more years senior to another trainee’’. Ex-post-facto design is ‘‘a non-experimental research technique in which pre-existing groups are compared on some dependent variable; it is a type of study that can masquerade as a genuine experiment. This experiment appears to be a true experiment because of the way the groups are separated and the way the analysis is performed, but it is still subject to the same limitations as non-experimental research. The assignment of participants to the levels of the independent variable is based on events that occurred in the past; this is where the name is derived from. This nonexperimental research is similar to an experiment because it compares two or more groups of individuals with similar backgrounds who were exposed to different conditions as a result of their natural histories’’.
Notes on contributor DR BAHAA ABA ALKHAIL, MD, Dr. P. H., MME, is Professor and Chairman of the Family and Community Medicine Department, King Abdulaziz University, Faculty of Medicine, Jeddah, Saudi Arabia.
Acknowledgments The author would like to thank the third year medical students of the academic year 2011/2012 who participated in the study. The publication of this supplement has been made possible with the generous financial support of the Dr Hamza Alkholi Chair for Developing Medical Education in KSA. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.
Peer-assisted learning and its perception among medical students
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Near-peer-assisted learning (NPAL) in undergraduate medical students and their perception of having medical interns as their near peer teacher BAHAA ABA ALKHAIL King Abdulaziz University, Jeddah, Saudi Arabia
Abstract Introduction: A near-peer-assisted learning term (NPAL) is ‘‘a trainee one or more years senior to another trainee’’. The current study is aiming to determine the pattern of NPAL activities, to compare its effect on student’s course achievement score and to determine the perception of students regarding having near-peer clinical teaching from their fellow medical interns. Methods: A total of 189 third year medical students participated in the study. The study questionnaire contains three sections. The first is the focus group section, self-administered questions and lastly quality control section. Trained staff helped in conducting the data collection. Results: Clinical teaching with mentoring was experienced by 116 students (61.4%) from their assigned interns in the early clinical experience course. The results of the study showed higher course achievement grades for students who experienced mentoring with clinical teaching compared to those students who experienced mentoring only, but it did not reach statistical significance. The study also found that most medical students acknowledged and agree that their near peers medical interns could provide unique input in helping them mastering clinical and communication skills competencies, the average percent for the seven opinion questions of the response agree combined with strongly agree was 62%. Conclusion: In conclusion, third year medical students recognize the unique and important role of near peer teaching in under graduate medical education and its importance for their professional development. NPAL strategy should be encouraged and used in other medical schools. The benefits of NPAL to peer teacher and in late clinical medical years needed to be investigated in future studies.
Introduction
Practice points
Educators know that an ideal way to truly understand new material is to teach it. The use of students as peer educators provides many benefits to the student’s teacher and his or her classmates (Hartman 1990). Most medical professionals are expected to teach students as an integral part of their role as doctor, in fact ‘‘doctor’’ in Latin means ‘‘teacher’’ (Bulte et al. 2007). A near-peer teacher term is ‘‘a trainee one or more years senior to another trainee’’ and a peer-teacher is one at the same level (Bulte et al. 2007). Rodrigues et al. (2009) noted that many researchers use the terms ‘‘peer-assisted learning (PAL)’’ and ‘‘near-peer-assisted learning (NPAL)’’ interchangeably without reference to any seniority. Peer-assisted learning is an umbrella term encompassing a variety of collaborative and cooperative educational strategies, including peer teaching and learning, peer assessment, peer mentoring, and peer leadership (Aston & Molassiotis 2003; Scott 2005). Operational definitions of each specific type of
Medical students believes that their near peers can provide useful formative feedback on their clinical skills performance. Clinical skills well acquired from medical interns in a friendly environment and structured learning setting. Students believe near peer formative assessment could be fair. Introducing clinical skills teaching in early medical years is well accepted and appreciated from medical students. Near-peer teacher need to be knowledgeable and prepared to give clinical session.
PAL as in the literature are as follows: peer teaching and learning is student instructing student (Iwasiw & Goldenberg 1993); peer assessment and feedback is students evaluating other students’ products or outcomes of learning
Correspondence: Prof. Bahaa Aba Alkhail, Professor and Chairman of Family and Community Medicine Department, Faculty of Medicine, King Abdulaziz University, P.O. Box: 1374, Jeddah 21431, Saudi Arabia. Tel: +966 1 2 6060025; +966 505 682 037 (mobile); Fax: +966 1 2 6408403; E-mail: [email protected]; [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/S10033–S7 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1006602
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(Topping 1998); peer mentoring is a student relationship with another student that fosters nurturing, sharing, encouragement, and support (Glass & Walter 2000), and lastly peer leadership is students leading other students independently from the clinical instructor (Bos 1998). Researchers have suggested that PAL implemented in clinical education in order to augment and supplement the role of the clinical instructor can be intentionally planned, but regularly occurs unintentionally or incidentally (Hartman 1990; Mensch & Ennis 2002; Tolsgaard et al. 2007). Studies over the past two decades in nursing, physical therapy, and medicine document the planned and unplanned use of PAL as well as its benefits in laboratory and clinical medical education (Aston & Molassiotis 2003; Scott 2005). Research has also been conducted in these fields examining students’ preferences for PAL compared to other forms of clinical instruction (e.g., expert-led instruction) (Hartman 1990; Henning et al. 2006; Tolsgaard et al. 2007). Further rationale for peer teaching importance, and a possible explanation for the many positive outcomes is the concept described by Lockspeiser et al. (2008) named ‘‘cognitive congruence’’. Is basically the concept of sharing similar learning experience and knowledge between the peer teacher and learner due to the added close proximity in age? This allowed peer teacher to use meaningful language easily understood by their learners and given at different appropriate levels (Nestel & Kidd 2003). Leeper et al. (2007) suggest that cognitive congruence promotes student-learners feel more at ease with a peer- or near-peer teacher than with a senior clinician (Leeper et al. 2007). Peer teaching benefited peer teacher as well who can improve and consolidate their own knowledge and experience (content and process learning) (Bulte et al. 2007; Rodrigues et al. 2009). Researches regarding NPAL in clinical medical training in Arab counties are sparse. The objectives were to determine the pattern of the NPAL activities provided (mentoring only versus mentoring with clinical teaching); secondly, to compare the effect of the NPAL activities on student’s course achievement score; and lastly, to determine the perception of third year medical students regarding having near-peer clinical teaching from their fellow medical interns.
Materials and methods Study setting The ‘‘Early Clinical Experience’’ course (ECE) included 18 sessions of two hours twice weekly that spread over the first semester in the third year of medical school. The students taught history taking, physical examination, patient communication skills as well as getting acquainted with different hospital sections. Medical interns’ participation in the course was on a voluntary base and for the purpose of getting the third year students become acquainted with different hospital sections and services. Male and female third year student groups were formed during the course in the form of three students in each group, which were organized by the course instructor during the initial phase of the course and according to students’ preference. Interns were assigned to the students S34
groups of the same gender. Each medical intern practices either mentoring as part of the course objectives or mentoring plus clinical teaching in unintentional and voluntary base depending on the intern personal readiness and willingness. Giving clinical teaching by medical interns was not part of the course objectives, and was given without any prior preparation. The student’s assessment was in the form of two A-type MCQs summative written exams representing 80% of the total course marks, and a logbook representing the remaining 20%.
Study subjects, sample size and sampling technique Total population of third year medical students during the academic year 2011/2012 was 308 of which 242 participated with a returned questionnaire (118 were males and 124 females). Exclusion criteria: Students who attend the course for the second time or those who did not set for the mid or final exam were excluded. During the pilot study, two males and three females met these criteria and accordingly they were excluded.
Study design Ex-post-facto design, describing/analyzing results subsequent to knowing net outcome effect (retrospective). Ex-post-facto design is a non-experimental research technique in which preexisting groups are compared on some dependent variable; it is a type of study that can masquerade as a genuine experiment. This experiment appears to be a true experiment because of the way the groups are separated and the way the analysis is performed, but it is still subject to the same limitations as non-experimental research. The assignment of participants to the levels of the independent variable is based on events that occurred in the past; this is where the name is derived from. This non-experimental research is similar to an experiment because it compares two or more groups of individuals with similar backgrounds who were exposed to different conditions as a result of their natural histories (Lammers & Badia 2005).
Data collection methods, instrument used and measurements Instruments Questionnaire was developed for the third year medical students. The questionnaire contains three sections; the first is a focus group questions, then self-administered individual questions, and the last section, quality control section. Training in running out a focus group structured interview session was taken place to improve inter and intra-observer reliability coefficient. Before the individual interview, the structured focus group interview sessions were conducted within each male and female group. Collecting focus group response with consensus within the group that shared understanding views with interaction between them with no domination by one or two students added more valid and reliable information (data). Asking the number and duration of clinical teaching sessions after a period of two semesters and summer period may lead to recall bias that could be different between the male and the
Peer-assisted learning and its perception among medical students
female groups, but employing within group response with consensus (focus group) and controlling for gender will aid in minimizing this systemic bias. Basketball style was used where the question is asked; response is elicited, and then passed it off to another student. After the conduction of the focus group, students were asked to sit separately and answer the selfadministered questions. Variables Definition in the focus group section Type of NPAL practiced on students’ group, by asking them whether they had mentoring only or mentoring with clinical teaching from their assigned interns - Independent variable (Nominal). Seven questions assessing each students’ group experience, specific strong points, and area of improvements, with near peer clinical teaching given by their assigned interns (Nominal). Peer teaching between students (within the group) yes and no response - Confounding variable. Number of clinical teaching sessions given Confounding variable (Continuous). Average duration in minutes of clinical teaching sessions - Confounding variable (Continuous). Variables Definition in the self-administered section: Seven self-administered questions measuring student’s opinion regarding having interns giving them near peer clinical teaching or assessment with mentoring [Likert’s – five-point scale (Scored according to the following criteria: 1 ¼ strongly disagree with the statement, 2 ¼ disagree, 3 ¼ neutral, 4 ¼ agree and 5 ¼ strongly agree) (Ordinal)]. Variables Definition in the quality-control section: The questionnaire contained two contradictory questions for quality control of student’s response (Validity). Finally, the questions regarding level of completeness, the accumulative grade point average (GPA) and course achievement score. (GPA) - Confounding variable (Continuous). Then categorized to two levels 4 and 44. Course achievements score (CAS) - Dependent net outcome variable (Continuous) that was changed to binary variable, grade AþB versus CþD (Nominal).
Data management and analysis plan Data entry, cleaning, and manipulation was performed using Statistical package of Social Science (SPSS) program version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, version 20.0, Armonk, NY). Descriptive analysis using tables, graphs, and numeric presentation was used. The normally distributed continuous variable was presented in the form of mean and standard deviation, for qualitative variables median was used. Nominal variables will be presented by mode and ordinal variables by median. Bivariate analysis, using student t-test for continuous outcome with binary independent variable and chi-square test for two categorical variables. Multiple Logistic Regression was used to test hypothesis and not to predict variables, forced technique (Method: Enter in SPSS) was employed where all the variables were included in the model with course achievement score as binary outcome in two levels, grade A þ B versus C þ D categories to test the effect of NPAL alone and with its
interaction with gender using dummy variables controlling for confounding. Odds ratio (OR) and 95% confidence interval (CI) were used to assess the strength of association and its significance. All statistical tests were significant at the level of p value50.05, with two tails probability.
Pilot study A sample of 20 students from the previous academic year, 2010/2011, were selected for the pilot study. The questionnaire was checked for ambiguity of questions, mutually exclusive and singularity in responses. Time needed to complete all sections of the questionnaire as well as the level of training of assistant students on running focus group interview sessions were assessed to improve inter and intra-observer reliability measures. Testing the content validity of the questionnaire revealed clarity and no confusion from the questions asked, face validity (expert review) done by four faculties specialized in Medical Education. Reliability of the questionnaire was at Cronbach’s alpha ¼ 0.83 for all questions; Cronbac’sh alpha ¼ 0.79 for characteristics of near peer clinical teaching practices questions; and Cronbach’s alpha ¼ 0.87 for students opinion regarding having near-peer clinical teaching or assessment by interns.
Ethical considerations Using interviewed questionnaire with coded names and identification numbers. Informing the students about the purpose of the study verbally and in a written form on the cover page of the questionnaire was employed. Coding key was kept in a safe and secret place where only the investigator can access it, since the study discloses and check the level of medical intern’s professionalism and competence, but without requesting the name of the interns. Final written report of the course evaluation were shared and discussed with key stakeholders before submitting or presenting it.
Results Of the 242 third year students participated, only 189 (78.1%) completed the study questionnaire with a valid and nonmissing responses, of which 89 (49.1%) were males. Clinical teaching with monitoring was experienced by 116 students (61.4%) from their assigned interns in the early clinical experience course. Percent of male and female students experiencing clinical teaching with monitoring was similar 61.8% and 61.0%, respectively. Table 1 shows that 61.21% of students reported having 4–6 sessions during the course period and that 43.1% of these sessions were planned ahead by the medical interns (Table 2). Students’ opinion regarding having near-peer clinical teaching or assessment from their fellow medical interns is shown in Table 3. Seven opinion questions were used and coded as follows; strongly agree coded 5, agree coded 4, no opinion coded 3, disagree coded 2 and strongly disagree coded 1. Female and male students showed median opinion score of agree level regarding having different NPAL activities (Table 3). The total median score for the seven opinion questions was 26 (maximum possible score 35) and for each
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question median score of 4. The average percent for the seven questions of the response agree combined with strongly agree was 62%. The two levels of NPAL activities and student course achievement grade variables showed the same total median score of students’ opinion regarding having near-peer clinical teaching or assessment (which was 26), correspond to level agree in the five-point Likert’s scale. Students who experienced clinical teaching with monitoring had higher percent of grade A combined with grade B than those students who experienced monitoring only, 79% versus 70% (Figure 1). On the other hand, testing this relationship using independent-samples t-test showed no significant
Table 1. Near-peer clinical teaching practices given by assigned medical interns.
Variable Number of clinical teaching sessions
Duration of clinical teaching sessions (min)
Category
Frequency
Percent
1–3 4–6 46 Total 30 min 430–60 min 460 min Total
30 71 15 116 23 57 36 116
25.86 61.21 12.93 100% 19.83 49.14 31.03 100%
difference in the mean score of course achievement between these two groups. Using logistic regression analysis with course achievement score as the dependent variable categorized into two levels (grade A þ B coded 1 versus grade C þ D coded 0) and near-peer-assisted learning (NPAL) as independent variable with two levels (monitoring only coded 0 and monitoring with clinical teaching coded 1) showed no significant association, controlling for grade point average, number of clinical teaching sessions, average clinical teaching sessions duration in minutes, and gender (Table 4). No significant association was found when the interaction term of gender with NPAL was added into the model. Selection bias may have occurred having groups with high GPA students cluster together and insisting in having medical interns assigned to them practicing mentoring with clinical teaching, while other groups of students with average or low GPA tend usually to cluster together not insisting or caring for such an issue. Statistical analysis using multiple regressions did 100%
1
3
90%
21
D C B A A+
21 80% 70%
37 60% 19 50% 40%
Table 2. Third year medical student’s experience of near peer clinical teaching given by their assigned medical interns.
18
30%
38
20%
Near peer clinical teaching practices with positive response The intern plan well for the each sessions The intern is competent in providing the session (teaching, feedback, and assessment) The intern practice communicating skills with us The intern understand our needs as students The intern help me to acquire clinical skills
Frequency
Percent
50 86
43.1 74.14
10%
14
17
0% Mentoring
Mentoring with clinical
NPAL 94
81.03
72
62.07
84
72.41
Near Peer Assisted Learning
Figure 1. Near-peer associated learning (NPAL) with course achievement grade.
Table 3. The median and percent score of student’s opinion, regarding having near-peer clinical teaching or assessment by interns*.
Opinion questions Clinical teaching sessions given by the intern were satisfactory Formal assessment and feedback by the intern were satisfactory Clinical teaching knowledge given by the intern will enhance my clinical knowledge Clinical teaching skills given by the intern will enhance my clinical skills Communication skills practiced by the intern during the sessions will enhance my communication Skills Formal clinical assessment by the intern will be valuable to me Clinical skills will be acquired well from the intern than from the consultant
Male (n ¼ 89)
Female (n ¼ 100)
Total (n ¼ 189)
% Agree þ strongly agree
4 4 4
4 4 4
4 4 4
58 61 64
4 4
3.5 3
4 4
54 62
4 4
4 4
4 4
65 63
*Opinion questions coded; strongly agree coded 5, agree coded 4, no opinion coded 3, disagree coded 2, and strongly disagree coded 1.
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Peer-assisted learning and its perception among medical students
Table 4. Multiple logistic regressions for course achievement score**.
95% C.I. For (OR) Variable name NPLA^
GPA* GENDER# NCTSD
DCTS
Category Mentoring only Mentoring with clinical teaching 4 44 Male Female 1–3 4–6 46 30 min 30–60 min
p Valueþ
Odds ratio (OR)
Lower
Upper
0.8
1.0 1.54
_ 0.37
_ 6.33
0.005
1.0 4.12 1.0 0.2 1.0 0.61 0.55 1.0 1.40
_ 1.91 _ 0.09 _ 0.14 0.10 _ 0.36
_ 8.87 _ 0.47 _ 2.56 3.24 _ 5.48
0.005 0.76
0.21
(**)Outcome variable 0 ¼ grade A þ grade B (N ¼ 143), 1 ¼ grade C þ grade D (N ¼ 46). (þ)Sig. (2-tailed) t-test. (^)Near–peer-assisted learning: mentoring only ¼ 0, mentoring with clinical teaching ¼ 1. (*)Grade point average 4 ¼ 0, 44 ¼ 1. (#)Male ¼ 0, Female ¼ 1. (D)Number of clinical teaching sessions. ()Duration of clinical teaching sessions in minutes.
overcome this confounding effect by controlling for the variable GPA.
Discussion Peer-assisted learning (PAL) has been embraced by medical educationalists for many years (Hartman 1990; Aston & Molassiotis 2003; Scott 2005). In fact, the benefits of PAL have been extensively described and are reputed to positively correlate with examination performance (Aston & Molassiotis 2003; Scott 2005). Figure 1 showed that course achievement grades for students who experienced mentoring with clinical teaching was higher than in those who experienced mentoring only, but it did not show a statistical significance (Table 4). This could be due to three reasons, judging the quality of clinical teaching by third year medical student as well as the competency of medical interns in giving clinical skills sessions could have been misclassified since this was their first encountered experience with clinical teaching. In the present study, 72.41% of the student who experienced clinical teaching from the interns reported that they had peer teaching from their classmates. The 43.1% and 74.14% figures of reporting that clinical teaching sessions were planned ahead by their assigned interns and that their assigned interns were medically competent in teaching clinical skills, respectively, might have been overestimated (Table 2). Lastly, course achievement score, which is the course assessment, may not reflect clinical skills assessment since it is in the form of two written A-type MCQs exams and a logbook reflecting hospital’s observation practices only. Clinical skills acquired from the clinical skills sessions during the course could not have been assessed by the present course assessment format. The course stakeholders are revising the course study guide to incorporate more basic clinical skills using the medical school state of the art skill lab facilities. The benefits associated with PAL, however, are not confined to examination scores only. Other student benefits
recognized are those of lowering subjective distress that could occur from (Bulte et al. 2007; Silbert & Lake 2012) negative experiences during the course of clinical teaching taught by faculty teacher showing a lack of appreciation and verbal abuse. Researchers have also shown that pairing junior and senior undergraduate students establish psychological and social support system and aids professional and personal development (Scott 2005; http://www.ncbi.nlm.nih.gov/ pubmed/2252487; Iwasiw & Goldenberg 1993) as peers can prove powerful positive role models (Topping 1998). The advantages of PAL do not appear to be limited just to the peer learners; peer teacher also have been shown to benefit significantly in this learning environment (Glass & Walter 2000). In fact, in some studies, it has been shown that peer tutors appear to show significantly greater cognitive gains than their peer learner counterparts (Somervell 1993; Bos 1998; Josephson & Whelan 2002; Mensch & Ennis 2002). Nearpeer teaching during medical school appears to be an important curricular consideration; it prepares future physicians to serve as educators for both junior physicians and patients (Hartman 1990; Mahdi et al. 2013). Interaction of students with their peers in a classroom setting and attempting to answer questions from the group, peer educators may gain insight into which concepts they have a thorough understanding of and for which they need to study further. Trained student teachers can be as good as associate professors in teaching clinical skills. The present study showed that the number and duration of NPAL activities with clinical teaching were limited, since only 12.93% of all third year medical student who experienced clinical teaching had more than six clinical teaching sessions in the whole period of the course, while only 31% of them said that some of their sessions lasted more than 60 min (Table 1). Since the study was targeting the peer learner and not the peer teacher, the practice of training the interns was not investigated nor asked, although prior training and later supervising the interns are very important to
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minimize tutors’ uncertainties (Secomb 2008; Weyrich et al. 2008). The present study found that most medical students acknowledged and agree that their near peers could provide unique input in helping them mastering clinical and communication skills competencies together with comfort in feedback and assessment (Table 3). Accordingly, teaching feedback to early medical students resulted in improved skills of delivering corrective specific feedback to their fellow students, not all medical education studies supported this, some reported resistance to peer evaluation (Somervell 1993; Searby & Ewers 1997; Topping 1998), especially if these assessments are summative and composing the final grade rather than the formative one. This present study provides two new pieces of information on near peer assessment. First, medical students in KAU believe that their near peers can provide useful formative feedback on their performance; secondly, and even more important, is that students believe near peer assessment is fair. The present study had limitations; first pre-test for third year medical students was not possible since the study is retrospective, so any gain in clinical practice, if identified, could be due to previous experience in clinical practice from other courses in first and second medical years. This is less likely since the third year in the medical program in KAU is the first year for students encounter with clinical teaching, besides ECE course is the first course in the third year medical curriculum. In this study, the incomplete-questionnaires were 53 of 242 returned questionnaires or 21.9%. Data from non-participants was not available regarding their thought about NPAL and so comparison of respondents with non-responders data was not possible. Lastly, the study was conducted using a single course on third year medical students in a single medical school with a hybrid curriculum, so the results may be generalized but with caution for other settings. One goal of future research should be answering the question of how peer student teachers can benefit from their experience. Our study design only allowed us to conclude students benefited from NPAL as peer students. The NPAL process does not only include the time spent in the classroom teaching, but also the time spent preparing for the session and its benefits through reflecting upon it. Determining to what extent each of these aspects contributed to the student’s gain of knowledge are not fully investigated although its benefits to both peer student and peer student teacher is well documented (Josephson & Whelan 2002; Secomb 2008). The research findings indirectly support the recommendation that training and planning ahead for clinical teaching sessions by near peer teacher is vital, and training in feedback and assessment enhances successful implementation of a peerevaluation system (Secomb 2008). The results suggest that students’ perception of peer teaching was positive and more clinical sessions can be considered in future (Secomb 2008). Further studies are required to confirm the magnitude and benefits of NPAL in late clinical medical years rather than third year where clinical teaching is well established, its concept understood and highly practiced as part of every course study guide (Mustafa et al. 2011). S38
Conclusion and recommendation Near-peer-assisted learning strategy should be encouraged and used in undergraduate medical education throughout the medical curriculum. Third year medical students recognize the unique and important role of near peer teaching in under graduate medical education and its importance for their professional development. Further studies are needed to show the magnitude of NPAL benefits in late clinical medical years for near peer students. Readiness, organization, and competence of the near-peer teacher are essentials in the learning process; further research is needed to show the benefit of NPAL practice to the near-peer teacher. Stakeholders were feed-backed regarding study findings and instructed that planned and organized clinical skills sessions by near-peer medical interns to their fellow third year medical students should be part of the future course learning objectives.
Glossary Near-peer-assisted learning term NPAL is ‘‘a trainee one or more years senior to another trainee’’. Ex-post-facto design is ‘‘a non-experimental research technique in which pre-existing groups are compared on some dependent variable; it is a type of study that can masquerade as a genuine experiment. This experiment appears to be a true experiment because of the way the groups are separated and the way the analysis is performed, but it is still subject to the same limitations as non-experimental research. The assignment of participants to the levels of the independent variable is based on events that occurred in the past; this is where the name is derived from. This nonexperimental research is similar to an experiment because it compares two or more groups of individuals with similar backgrounds who were exposed to different conditions as a result of their natural histories’’.
Notes on contributor DR BAHAA ABA ALKHAIL, MD, Dr. P. H., MME, is Professor and Chairman of the Family and Community Medicine Department, King Abdulaziz University, Faculty of Medicine, Jeddah, Saudi Arabia.
Acknowledgments The author would like to thank the third year medical students of the academic year 2011/2012 who participated in the study. The publication of this supplement has been made possible with the generous financial support of the Dr Hamza Alkholi Chair for Developing Medical Education in KSA. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.
Peer-assisted learning and its perception among medical students
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