Tomorrow's Doctors and Nurses: Peer assisted learning

Tomorrow’s Doctors andNurses: Peer assistedlearningDeborah Gill1, Carol Parker1, Melanie Spooner1, Marianna Thomas1, Kate Ambrose2

and Jane Richardson1, 1Royal Free and University College London Medical School, 2Schoolof Health and Social Sciences, Middlesex University

INTRODUCTION

The General Medical Councildocument Tomorrow’sDoctors1 sets out the

requirements with regard to basicmedical education in the UK.Among the competencies expec-ted of graduates are those thatrelate to teaching and learning.Over last five years, the Royal Freeand University College MedicalSchool (RFUCMS) has built up arange of activities to encouragestudents to develop their skills inteaching, learning and assess-ment and to engage in co-opera-tive learning. The most successfulof these initiatives has been thedevelopment and implementationof a range of peer assisted learn-ing activities (PAL). In thebroadest sense PAL can be des-cribed as ‘people from similar

social groupings who are not pro-fessional teachers helping eachother to learn and learning them-selves by teaching’,2 but the termcovers a wide range of activitiesand strategies including groupprojects and learning activities,peer mentoring and support, andpeer tutoring.3

PAL is common to pre-school,primary, secondary, tertiary andwork-based education and there isnow an increasing body of empir-ical evidence supporting theefficacy of peer assisted learningin medical settings.4–8 PAL has astrong history at University Col-lege London. Well-constructedand well-supported PAL schemeshave been shown to be successfulin a broad range of educationalsettings,9 and have becomeembedded within the core curri-

culum in a wide range of faculties.The medical school introduced thefirst PAL initiative in 2000 and,with the support of teaching staffand students, PAL has become asignificant and popular compo-nent of the medical school curri-culum.

As PAL became an establishedpart of the undergraduate experi-ence and the demand for involve-ment in PAL activities fromstudents grew, the Academic Cen-tre for Medical Education (ACME)looked for new ways of imple-menting peer assisted teachingand learning activities. The NHSplan10 stresses the need to developmulti-professional learning envi-ronments which focus attentionaway from the needs of individualprofessions and towards thepatient. With this in mind the first

PAL has a stronghistory atUniversityCollege London

Focus onRFUCMS

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interprofessional PAL initiativewas piloted in 2004, and ACME nowprovides two student selectedcomponents (SSCs) each yearoffering 38 final year medical stu-dents the opportunity to beinvolved in PAL with their nursecolleagues. These final year SSCsutilise a version of PAL involvingfixed role peer tutoring. This can bebest described as ‘at any one time,someone has the job of tutor whilethe other(s) are in the role astutee(s)’.11

THE INTERPROFESSIONALPEER ASSISTED LEARNINGPROJECT

The learnersThese are senior nurses underta-king Developing the Nurse Practi-tioner, a post-registration orgraduate course, run by theSchool of Health and SocialSciences at Middlesex University.This course is designed for nurseswho are preparing to becomenurse practitioners in emergencyor primary care. A number of themodules during the course includedeveloping knowledge and skillsin physical examination andphysical assessment. One of themodules is also undertaken bynurses who are developingadvanced practice skills in orderto work autonomously in special-ist clinics, critical care outreachteams, pre-operative assessmentand as night nurse practitioners.

Compared with medical stu-dents, the nurses have a shorttimeframe to develop and practisephysical examination and physicalassessment skills and thus theclinical skills sessions in thesemodules require intensive timelysupport. The aim of these sessionsis to prepare learners to be able topractise these newly masteredskills in their own clinical practiceareas. Lack of consistently avail-able teaching staff meant thatslightly differing approaches tophysical assessment were beingtaught in these sessions andsupervision of practice was below

the desired standard. This createduncertainty which left the learn-ers feeling uncomfortable.

Nursing lecturers approachedACME teaching staff to look at waysof providing both consistency inteaching that conformed with theways in which future doctors werelearning these skills, and supportin supervision of learning. Inter-professional peer assisted learningwas proposed as a way of meetingthe needs of the nurses whilst alsoachieving benefits for medicalstudent teachers.

The peer tutorsFinal year medical students whohave opted to complete a SSC inteaching act as peer tutors on theDeveloping the Nurse Practitionercourse. At the beginning of the SSCthese students participate in a

two-day intensive ‘TIPS’ coursewhich is based on the courseprovided by ACME for postgraduateclinical teachers. This is accom-panied by weekly seminars in spe-cific teaching skills includinggiving feedback, assessment, andteaching complex topics. Studentsalso have a number of sessions runby teaching staff to enable them toconsolidate their physical exam-ination skills and practise theirteaching skills.

Peer tutors in liaison with themodule leads work on preparingthe teaching sessions to achievethe module curriculum goals. Peertutors mainly use small grouppractical sessions to deliver theteaching and also prepare anyadditional teaching materials theyplan to use. Teaching staff fromboth the school of nursing and

Nurses have ashort timeframeto develop and

practisephysical

examination

14 THE CLINICAL TEACHER March 2006 | Volume 3 | No 1| www.theclinicalteacher.com

ACME are on hand during theteaching sessions to provide sup-port and regular one to one obser-vation of teaching with feedback.

One of the SSCs also involvesPALs in running a formative OSCEto prepare the learners for theirend of module assessments.

EVALUATION

In total, three modules lastingfour weeks and involving a totalof 36 medical student tutors and58 learners have been run sinceearly 2004.

A wide range of evaluationmethods was used to evaluate thisinitiative. The evaluation encom-passed both written and oralfeedback and looked at theacceptability of the initiative totutors and learners, the perceivedprogress and outcomes of bothlearners and tutors, the actualperformance of the learners andthe practicalities and ongoingfeasibility of the project.

PAL is one of the most popularSSC choices for final year studentsand the evaluation of this project,

Peer tutorsanticipatedgains inconfidence

Table 2.

Sessions in the Developing the Nurse Practitioners Course utilising medicalundergraduates as PAL tutors

• Basic anatomy and physiology of the respiratory, abdominal cardiovas-cular and nervous systems, eyes, ENT

• History taking and documentation skills

• Examination skills; Respiratory abdominal, cardiovascular and nervoussystems

• Physical assessment and diagnostic skills

• Principles of prescribing

• End of module assessment practice

Table 1.

Features of peer assisted learning student selected components at theAcademic Centre for Medical Education

• Four week module

• Peer tutors attend a ‘TIPS’ course to equip them with basic teaching skills

• Learning for Teaching sessions; sessions with teaching staff to revise andconsolidate knowledge and skills in the areas to be taught

• Peer tutoring method adopted (fixed tutor:learner role)

• Peer tutors work with small groups of learners using simulated patients orvolunteers, mainly in a skills centre setting

• Peer tutors have regular observation and feedback on performance byACME teaching staff


as with other more established PALactivities, provided a wide range ofpositive outcomes for tutors,learners and teaching staff.

Peer Tutors ExperiencesBefore undertaking the teaching,questionnaire data suggested thatpeer tutors anticipated gains inconfidence, knowledge and under-standing of the subject, gains inteaching and clinical examinationskills and an opportunity to en-hance interprofessional relation-ships. They felt the atmospherethey could provide for learningwould not be intimidating and theimproved learner-to-teacher ratiowould result in better learningopportunities. They were con-cerned that nurses might be moredifficult to teach than medicalstudents, particularly in view ofthe mixed abilities and knowledgeof the group. There were alsoconcerns about being perceived aspatronising and feeling intimid-ated due to nurses’ superior clinicalexperience.

It is said that ‘to teach is tolearn twice’11 and certainly thepeer tutors’ log diaries, end ofmodule questionnaires and focusgroup discussions all revealedperceived gains not only in theirteaching and presentation skillsbut also in their clinical andcommunication skills;

‘Learnt from doing it yourself –both the examinations and teach-ing skills’ (Focus Group)

‘Opportunity to revise teachingmaterial’‘Becoming more competent andconfident in examinations’. (End ofmodule questionnaire)

Peer tutors also reported abetter understanding of nurses’roles and competencies;

‘good for building relationshipsbetween professionals’‘breaking down interprofessionalbarriers’ (End of module ques-tionnaire)

There was still some lack ofclarity, but a willingness to learn;

‘I’m still not sure what nursesdo and don’t do – a nursing weekwould help’ (Focus Group)

As anticipated, there weresome difficulties experienced inteaching the nurses;

‘(Teaching) was very difficult topitch as it was unclear how muchdetail was needed and studentswere of very different levels’

‘(The worst aspect of theteaching was) approaching andtrying to teach people who havemore clinical experience than me’(End of module questionnaire)

Learners experiencesThe learner group was on thewhole very positive about theproject. The pre-course question-naire revealed that the learnersanticipated a different approachto learning where they wouldreceive support and guidance andwhere the tutors were on the‘same level’ as them and wouldexplain the basics.

They felt the learning would betwo-way, with the medical stu-dents seeing a more holistic viewof patients and gaining insightinto how nurses learn and practise,and an opportunity for both partiesto build positive interprofessionalrelationships.

Most had no anxieties aboutthe teaching at the outsetalthough a minority of learners (4of the 58) expressed some con-cerns about the use of jargon,whether the peer tutors wereexperienced enough to teach,whether their knowledge base andpractical skills would be as greatas those of the learners andwhether their skills at teachinghad been assessed.

The vast majority of learners(51 of the 58 in an end of modulequestionnaire) were positive

Peer tutorsworked hard to

deliver highquality

teaching


about medical students as peertutors. They felt the best aspectsof the teaching were deemed tobe the ‘hands on’ style, the up-to-date and broad knowledge of thestudents, their lack of ‘bad hab-its’, good teaching methods andenthusiasm and approachability.

‘The peer tutors in my groupwere lovely, helpful – honest. Theymade the session interesting …our responses were used andrespected.’

‘They had so much interest andcommitment to our cause –I foundthem very supportive andencouraging.’

‘They knew the subject and howto put it across. They also took intoaccount our experience.’ (End ofmodule questionnaire)

In addition the learner focusgroup discussion also revealedthat the nurses had developed anunderstanding of medical studentlearning needs and they will nowencourage junior nursing staff totalk to medical students more;

‘… I discovered many commonareas; they’ve gone up in myopinion!’ (Focus Group)

2005 represented the firsttime that the majority of thephysical assessment module wastaught by PALS and all nurseparticipants from the 2005 cohortwho sat the end of moduleassessment passes the OSCE com-ponent of the examination.

Teaching staffTwo members of the school ofnursing teaching staff were inter-viewed and they reported that theuse of peer tutors led to gains inthe quality of teaching; partic-ularly the clinical skills componentof the modules. The use of peertutors also enabled the provisionof small groups for teaching andsupervision and ensured timelyfeedback on performance. Theyfound the peer tutors professional

in their approach and noted thatthey paid particular attention tothe needs of their learners andmade attempts to get the pitchright and use a variety of teachingaids. Both interviewees felt thatthe ability of learners as theyapproached the end of moduleassessment had become more

consistent and learners felt morecomfortable with OSCEs.

Medical school teaching staff,already champions of PAL, foundthrough observation of teachingthat the peer tutors worked hard todeliver high quality teaching andquickly became independent and

Table 3.

Evaluation methods used to evaluate theinterprofessional PAL project

Learners

• Pre course questionnaire concerning their preconceptions about beingtaught by medical students. (a combination of Likert scales and free textquestions)

• An end of module questionnaire about their perceived learning, experi-ences and feelings about the project(a combination of Likert scales andfree text questions)

• An end of module focus group discussion with purposeful sampling tocapture a range of peer tutors

• Performance in the end of module OSCE

Peer tutors

• Pre course questionnaire about their preconceptions and feelings aboutbeing involved in the teaching (a combination of Likert scales and freetext questions)

• Written feedback in the form of reflective log diaries and confidenceratings

• An end of module questionnaire about their experiences and feelingsabout the project(a combination of Likert scales and free text questions)

• An end of module focus group discussion

Teaching staff

• Interviews with key members of teaching staff from both the medicalschool and nursing school (two school of nursing teachers and threemedical school teachers)


resourceful teachers. Medical stu-dent were at first apprehensiveabout teaching very senior nursesbut feedback from previous cohortswas useful to calm some of theseinitial fears. It was felt by all threeof the interviewees that buildingrespectful relationships betweensenior medical students and nurseswas a particular benefit to comeout of this PAL initiative.

THE FUTURE

In recent years there has been astrong drive for medical schoolsto work more closely with otherorganisations providing educationfor the health professions. Inter-professional education has beenshown in some studies to assistthe transfer of knowledge andskills, the development of pro-ductive professional relationshipsand changing the attitudes andperceptions of participants byreducing negative interprofes-sional stereotypes.12–14

This initiative built on anexisting ‘culture’ of PAL within themedical school as both a way ofextending PAL opportunities formedical students who need todevelop teaching skills in theundergraduate years, and as apotential way of promoting inter-professional learning activities.

Interprofessional educationcan be said to occur when ‘two ormore professions learn from andabout each other to improve col-laboration and the quality ofcare.’15 The limitations of thisinitiative as an interprofessionalactivity is the lack of learningfrom each other; the formalteaching was non-reciprocal.However the evaluation data re-vealed that there was a degree ofexperiential learning about eachother. There is still much work todo in utilising PAL in interpro-fessional settings and the aim isnow to look at further opportun-

ities; in particular reciprocal peertutoring, where the tutor:tuteerole is not fixed and both groupslearn from each other.

Although senior nurses andfinal year medical students may notat first seem like similar socialgroupings in the original definitionused,2 they are both groups oflearners in a healthcare settingwhere roles of professions are rap-idly changing. Importantly, eachas a group has a body of knowledgeand competencies that can beshared This initiative has shownthe suitability of senior medicalstudents and senior nurses as asuitable peer learning partnership.It offers a way for medical studentsto develop their competencies asteachers whilst also bringingtogether medical students andnurses in a learning environmentthat encourages learning abouteach other. It allows medical stu-dents to share their recently mas-tered competencies with fellowhealth professionals who will beutilising these skills alongsidethem in the modern NHS.

Even in a medical school with aPAL ‘culture’ it is important toembed such initiatives formallyinto the curriculum. This takes thecontinued effort of teaching staffto evaluate such activities andcommunicate findings widely toencourage a better understandingamongst teachers and health careprofessionals of the benefits andfeasibility of both PAL andinterprofessional teaching andlearning.

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Tomorrow's Doctors and Nurses: Peer assisted learning