Peer Assisted Learning in Allied Health Professional Clinical Education

Peer assisted learning (PAL) is an educational approach supported by social learning theory and involves students learning with and from each other. Peer assisted learning has been utilised and researched extensively within the classroom setting and the basis of its success lies in its capacity to empower active involvement from students in their own learning. Reports on PAL in health professional education suggest that not only is PAL an effective strategy for developing students’ knowledge and clinical skills, but importantly the process of PAL can also assist in the development of productive learner behaviours and professional skills such as communication and collaboration. There are many different types of PAL: it can be formal or informal, structured or unstructured, intentional or unintentional and with or without facilitation.
   Despite promising results in classroom-based health education, the uptake of PAL in the clinical education setting has been less common. Peer assisted learning can be utilised when clinical educators supervise more than one student concurrently, however traditionally allied health clinical education has been undertaken in a 1:1 student : clinical educator model. The benefits of implementing PAL in the clinical education setting may be twofold: it may be an effective learning strategy for students and may also form a framework by which clinical educators could supervise multiple students concurrently, potentially assisting in addressing the shortfall in clinical placement availability.
   Literature pertaining to alternative ‘multiple student to clinical educator’ placement models is emerging in allied health professional education, predominantly examining the effects of the 2:1 or ‘paired’ model, where two students are supervised by one clinical educator. Peer assisted learning is often cited as one of the factors contributing to the success of the paired student clinical education model, however PAL may or may not occur, depending on various factors within the context of the learning environment. Reports on paired student clinical education models to date have often failed to define PAL or measure and report on the occurrence and effects of PAL within the model. To examine this further, this research aimed to investigate the types of PAL that are acceptable to students and clinical educators within the paired student clinical education model, and the effect on student learning and clinical educator service delivery.
   Three studies were conducted within the research program, examining paired allied health professional clinical placement models with same-level peers (as opposed to near peers, or students from different year levels) specifically in the clinical placement setting. The research program utilised a mixed methods approach, incorporating various designs of qualitative and quantitative investigation across different allied health professions and different clinical placement settings.
  Study 1 utilised a participatory approach, involving clinical educator stakeholders in the development of a paired placement model which specifically aimed to promote PAL within the model. Study 2 involved a randomised cross-over design to trial the PAL model developed, compared with a ‘traditional’ approach to paired placement models where PAL was not actively facilitated. Study 3 utilised a stepped wedge design to examine the effects of the clinical educator training module associated with the PAL model. Finally, the results of all three studies were synthesised with the results of the systematic literature review and the relevant educational theory to develop recommendations for PAL implementation.
   The findings from this program of research support the use of PAL as an educational strategy for allied health professions in the clinical setting. Benefits reported by clinical educators included reduced educator burden, improved use of student ‘downtime’ and that PAL helped students to build professional skills such as teamwork, communication and feedback capabilities. Students reported that the psychological safety created by PAL enabled them to raise concerns about their own knowledge and practice, when compared to working with an expert other. Both students and educators gave examples of where PAL helped to position students as active learners through reduced dependence on the clinical educator. Cohesion of the student to student relationship was seen as an enabler of successful PAL, and there was also agreement that collaboration is a professional expectation.
   The RCT (study 2) demonstrated that specific PAL activities can be integrated into the clinical education of paired students without sacrificing student performance outcomes. Although the quantitative data supported some positive outcomes under the PAL model, both educators and students were more satisfied with the traditional approach. The rigidity of the prescribed model was cited as the major source of dissatisfaction. This clear finding informed the design of the multidisciplinary trial (study 3) where clinical educators and students were not required to adhere to a prescribed model with mandated frequency of activities, but instead were trained and supported to implement the elements of the PAL model flexibly.
   Clinical educators identified that facilitating PAL is a complex skill which takes education, resource and time to develop. When clinical educators were provided with training in PAL (study 3), their perceived confidence to facilitate PAL improved, there was a self-reported change in their education behaviours and some changes in the PAL activities students undertook whilst on placement. Students reported that PAL enhances the clinical learning experience, but it was not a replacement for skilled clinical educator practice modelling, feedback and guidance. The importance of skilled educators was highlighted to mitigate challenges associated with managing peer relationships and maintaining individualised feedback in the paired model.
   This comprehensive research program informs the current discourse on PAL in allied health professional clinical education. It is the first published research program designed to specifically examine the effects of PAL occurring within a paired student clinical education model and the first to measure the effect of training clinical educators in facilitating PAL on student reported activity. The program has developed and tested a repeatable, quantifiable PAL model for the clinical education of paired students. The model has been refined based on empirical findings and stakeholder feedback to produce a flexible PAL framework to guide practice. Future work should focus on longitudinal studies investigating how students evolve in their peer learning practices over time, and whether these competencies influence their capacities to operate in the workforce. Longitudinal studies could also examine how clinical educators’ facilitatory practices change over time. The experimental designs and participatory approaches utilised in this research program may be applicable to many clinical and education contexts to develop further robust evidence in this area.