Peer assisted learning in undergraduate clinical medical education: a mixed methods study

Peer-assisted learning (PAL) involves students learning with and from each other. PAL activities may be informal, or undertaken formally in a curriculum, with or without educator facilitation. Reports on PAL in medical education suggest its value can extend beyond technical knowledge gain, to development of broader professional skills. However, the literature largely focuses on the value of PAL in the university environment, rather than how it occurs in the clinical context. Medical students at Monash University are required to engage in PAL in their pre-clinical years. The researcher’s experience as learner and teacher suggested students also formulated PAL strategies for clinical placements. However, activities were not formalised and unlikely to be optimised. This research aimed to identify students’ and educators’ use and perceptions of PAL during clinical placements to develop recommendations for PAL in clinical settings. A tri-phasic study was designed using Biggs’ Constructive Alignment as a framework to characterise students’ PAL experiences, examining the intended, enacted, and perceived curriculum. Year 3 was the focus of the study, as this first clinical year contains many unstructured learning opportunities which may afford PAL. Research methods comprised a curriculum map (Phase 1), student survey and an observational study of the students on their clinical placements (Phase 2), and interviews with experienced educators (Phase 3). Whilst the curriculum map identified few explicit learning objectives relating to PAL, students reported participation in PAL activities during clinical placements on average 20 times per week. Observations supported this reported frequency of peer interactions: two-thirds of students’ time was spent in the company of peers. Survey and interview data revealed students valued teaching and feedback from peers, but doubted the accuracy of peer-generated information. The roles of ‘feedback giver’ and ‘observer’ were less valued by students. Significantly more female students reported that PAL contributed to a safe learning environment than males. PAL activities were reported to contribute to students’ evaluative judgement: the comprehension of and ability to judge performance against notions of quality. Educator involvement was perceived to be a key ingredient for successful PAL. These data were used to develop a PAL Activity Matrix, which identified activities students could partake in within a clinical environment to optimise their learning. In Phase 3, expert educators reported the study findings resonated with their own broader experience of PAL in clinical education. The activity matrix was confirmed as representing ideal strategies. Potential barriers and facilitators to the uptake of PAL were illuminated. These ‘real world’ considerations for culture, epistemic authority, and patient-centred care were included in the resultant implementation framework for PAL. This comprehensive study informs the current discourse on PAL in clinical medical education. It identifies barriers and facilitators to PAL, and presents strategies to improve the value of PAL. Future work could test the effect of PAL strategies on students’ clinical capacity, including technical competency, professional and communication skills, and preparedness and ability to teach. The use of PAL could also be examined in a broader range of clinical environments, at both undergraduate and postgraduate levels.