Peer-Assisted Learning Strategies: A Comprehensive Review of Research

Peer-Assisted Learning Strategies (PALS) represent a multifaceted approach to education, leveraging the power of peer interaction to enhance learning outcomes across various disciplines and age groups. This article delves into the research surrounding PALS, examining its implementation, benefits, and effectiveness in diverse educational settings. From its origins in elementary reading programs to its applications in medical education, PALS has emerged as a valuable tool for fostering active learning, collaboration, and academic achievement.

Introduction to Peer-Assisted Learning Strategies

Peer-assisted learning (PAL) is a common teaching and learning method in medical education worldwide. PALS is a structured peer tutoring intervention that aims to improve student proficiency in several disciplines. During the sessions, students take turns acting as the tutor, coaching and correcting one another as they work through problems. The designation of tutoring pairs and skill assignment is based on teacher judgement of student needs and abilities, and teachers reassign tutoring pairs regularly.

PALS in Elementary Education

PALS-R: Fostering Reading Skills in Early Grades

As educators seek methods to address the diverse needs of learners and strengthen general classroom instruction, Peer Assisted Learning Strategies for reading (PALS-R or PALS) has emerged as a promising approach. PALS, modeled after ClassWide Peer Tutoring (CWPT), complements the existing reading curriculum by providing research-validated learning strategies through peer-mediated instruction. In the PALS approach, teachers pair a high-performing reader with a low-performing one in order to complete activities designed to promote the development of reading skills. In PALS, the student in the role of tutor is referred to as the Coach, while the student being tutored is referred to as the Reader.

PALS combines peer-mediated instruction with effective reading activities. These activities include phonological awareness exercises, decoding activities, fluency building, and comprehension exercises. Research indicates that most of the students who engage in this strategy demonstrate improved reading performance.

PALS-UK: Adapting the Model for a New Context

PALS was developed in the United States by Douglas Fuchs, Lynn Fuchs, and other researchers from Vanderbilt University. Peer Assisted Learning Strategies UK (PALS-UK) is a whole-class, structured peer tutoring intervention aiming to improve pupils' reading comprehension, oral reading fluency, and overall reading attainment. The intervention was adapted for the U.K. context and delivered by Dr Emma Vardy (Nottingham Trent University) and Dr Helen Breadmore (University of Birmingham).

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Pupils are paired and take part in four activities: partner reading (pupils take turns reading while their partner corrects any reading errors), re-tell (one pupil retells the passage just read with prompts from their partner), paragraph shrinking (each pupils reads a short passage and summarises what they have read), and prediction relay (pupils take turns to read and predict what will happen in the next half-page of the story). The programme was delivered by teachers who received one day of initial training from the PALS-UK team followed by a half-day top-up training. Pupils also received training from their teacher over the first four weeks of the programme to learn how to undertake the four PALS activities and work collaboratively with their peers.

PALS in Medical Education

PAL: A Mutually Beneficial Approach

In pre-clinical medicine, PAL has been established in particular in anatomy, physiology and problem-based learning. In clinical medicine, this method is applied above all for the training of clinical skills, such as communication, physical examination, different technical procedures and resuscitation skills. Furthermore, PAL is used to teach clinical procedures in specific programs for students who are currently doing clerkships or internships. The concept of PAL even seems to be suitable in the area of stress prevention at medical school.

PAL is mutually beneficial both for student tutors and student learners. On the one hand, PAL supports student learners’ cognitive, psychomotor and affective development. This results in an increase in self-confidence, autonomy, clinical reasoning, self-evaluation and peer collaboration. On the other hand, student tutors also benefit from this program and are able to improve their individual knowledge, skills and attitudes, while practicing interaction and leadership competencies. This can enable student tutors to become better learners themselves, which in turn helps their undergraduate medical education, future residency, and faculty membership.

Social and Cognitive Congruence in PAL

Some studies have shown that so-called ‘social and cognitive congruence’ between student tutors and student learners play an important role in PAL. As student tutors and student learners have similar social roles, it is assumed that they are ‘socially congruent’. This means that they share interpersonal qualities which facilitate informal and empathic communication as well as the establishment of a learning environment that encourages an open exchange of ideas and student learners’ personal concerns. The term ‘cognitive congruence’ refers to the assumption that student tutors and student learners are likely to share a similar knowledge base and similar learning experiences; they are on the same ‘wavelength’. This could mean that student tutors think of explanations that are more likely to meet the student learners’ needs and are therefore easier to understand. Thus, cognitive congruence could compensate for the lack of knowledge and expertise of peer-teachers compared to more experienced teaching staff.

Student Tutors in Skills Labs

Teaching procedural technical skills in skills laboratories (skills labs) has become an indispensable part of medical education and is common in many medical schools. Skills labs enable students to learn and practice specific procedures in a simulated and sheltered environment by using manikins, part-task-trainers, simulators, or simulated patients. In skills labs, it is quite common to have student tutors as teachers. Several studies have shown that the teaching methods of student tutors are either equivalent or even superior to those of more experienced teaching staff. For instance, student tutors were able to create a more active learning environment compared to professors when teaching procedural skills.

Motivation and Experiences of Student Tutors

One of the main motivating factors for student tutors to teach in a skills lab was the possibility to simultaneously share and improve their knowledge and expertise. In general, the participants of our study had high aspirations for their teaching. They found it particularly important to be empathetic with the student learners. At the same time, they thought they would personally benefit from their teaching activities and develop a certain expertise as student tutors.

PAL as a Supplement to Traditional Teaching

With the given background, it is customary to understand that PAL should not be considered as a substitute to teaching activities delivered by faculty but as an attractive and valuable supplement to the teaching and learning activities that can enrich the educational environment. A great proportion of PAL informally occurs in the absence of faculty, and the students happen to learn disproportionately when it is left to chance. Conversely, formalised and structured PAL can help facilitate the students to independently learn. Thus, a carefully designed PAL framework has the potential to facilitate student-oriented learning, particularly in interprofessional education and practice.

Meta-Analysis of PAL Effectiveness in Medical Education

Methodology

During January 2018, the databases of MEDLINE, ScienceDirect, Ovid, EBSCO, and Web of Science were searched using the Medical Subject Headings (MeSH) terms ‘peer-assisted’, ‘learning’, ‘active learning’, ‘teaching strategy’, ‘peer mentoring’, ‘peer instructions’. Accordingly, full-text English language studies published from 2005 to 2017 with pre-post designs were searched in the selected databases that quantitatively compared the impact of PAL in undergraduate and postgraduate medical and health science disciplines.

The inclusion criteria for selecting articles included 1) pre-post research design articles that explored the effectiveness of PAL in medical education and 2) empirical and original studies that published data with average and standard deviations. An initial search through selected databases yielded 2381 articles. Yet, during the analysis of abstracts of these studies, 522 articles were excluded due to duplications and publications. A further analysis excluded 1,791 studies due to the irrelevance of research work. Finally, 68 studies were found to be relevant; however, with regard to the full-text analysis of these studies, the researchers removed another 57 articles due to inappropriate data. Both authors performed independent literature reviews and selected and analysed studies. Regarding any differences in opinion and controversies, they reached a consensus by referring to the selection criteria and MeSH terms. In this study, the meta-analysis was done by utilising Review Manager (RevMan) 5.3 software developed by Cochrane Training.

Results

The results showed a significant effectiveness of PAL; notably, there was a standardised mean difference of 1.26 with a confidence interval of 0.58-1.94. The Cochran's Q test showed a 5% level of significance as measured by Chi2 = 449.46. This research has shown that PAL can be used as a valuable learning tool in the medical field. This validates the significant effectiveness of PAL as compared to a control group with a z value of 3.65 (p < 0.05).

Quality of Studies

The quality of each study was rated on a 5-point Likert scale with 1 being low and 5 being very high. The range of ratings in the selected studies showed 2 (two studies) and 4.7 (nine studies), while the mean quality of selected studies was 3.5. The strengths of the studies were considered by larger sample sizes, pre-post designs, educationally strong interventions, and appropriate data analysis.

Implications

This research provides substantial evidence that peer learning is a significantly effective tool for active learning in medical education.

Benefits of PAL

Cognitive and Meta-Cognitive Skills

The students in the PAL group performed significantly better in the theoretical (p < 0.001) and practical (p < 0.001) parts of the tests, while they showed similar results in the Objective Structured Clinical Examination (OSCE) for dentistry (p < 0.01). This study reflects some benefits of PAL in improving cognitive and meta-cognitive skills of the students; however, PAL failed to enhance the clinical skills of the study cohort.

Knowledge and Skills Enhancement

Buqai et al. have argued that teaching psychomotor skills in labs and training centres can be more effectively achieved by student tutors than by senior teachers. In this study, the authors have alluded that the most powerful motivation for student tutors remained the enthusiasm and aspirations to enhance their own knowledge and skills.

Learning Experience

PAL has been shown to be far more instrumental in enhancing the learning experience because it is relatively easy to organise and does not require keeping a formal timetable. Reciprocal peer learning underpins the emphasis on the learning process, including the emotional and intellectual support that learners offer each other.

Academic Performance

Awasthi and Yadav, using a small group discussion model of a tutor and four to six peer learners, have reported an improvement in student's performance and test scores after using PAL in a paediatrics course. The researchers conducted a pretest-posttest design and subsequently reported a 24% improvement in the posttest and a correlation of 0.48 (p < 0.0001) coefficient between the pretest and posttest scores. The improvement in the students' academic performance was also reported from a study conducted in the United Kingdom (UK), where PAL was used to conduct clinically-oriented tutorials in the pre-clinical module. The results of all five post tutorial quizzes which were used in the study showed a significant improvement in mean student score (p < 0.05).

Limitations and Considerations

Task Complexity

From our literature search on the effectiveness of PAL, we identified one study by Williams and Reddy where the students - utilising aseptic techniques in the PAL group - did not perform as well as the students in the other group. The authors have argued that this ineffectiveness of PAL might be attributed to the difficulty and complexity of the task being performed.

Mixed Results

A scoping review has reported six studies that showed no difference in students' academic performance among groups using PAL versus groups using teachers-led educational techniques. Similarly, a study by Cameron et al. did not find a significant difference in the students' performance in the final OSCE for dentistry between the students' who were involved in PAL and those who were taught by teachers in dental skills.

Further Research

Such reports provide a strong scientific impetus for conducting more studies on PAL in various disciplines that can help create a unified instructional strategy in medical education. Furthermore, there is limited evidence about the effectiveness of PAL for improving presentation skills, group work or projects, and spatial skills. The effectiveness of PAL in certain other medical disciplines has not been studied, and this shortcoming can imply validating these research findings. Another limitation was the selection of studies published in the English language.

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