Students’ Attitudes towards Extracurricular Clinical Skills Peer Teaching Sessions

Medical Science Educator © IAMSE 2013 Volume 23(4) 620

MEDICAL SCIENCE EDUCATOR The Journal of the International Association of Medical Science Educators Med Sci Educ 2013; 23(4): 620-627

ORIGINAL RESEARCH

Students’ Attitudes towards Extracurricular Clinical Skills Peer Teaching Sessions Christine McMenamin1 & Nicole Koehler2 1Monash University, Clayton, Victoria, Australia 2Deakin University, Melbourne, Victoria, Australia Abstract Background: Near-peer teaching, which involves a more experienced student teaching a group of less experienced students within the same course, has commonly been used in educational settings. Fifth-year medical students at The University of Western Australia offered extracurricular clinical skills sessions to third-year medical students. Aim: The aims of the study were to: 1) enumerate third-year students’ attendance at sessions and reasons for attending / not attending; 2) determine the usefulness of clinical skills topics; and 3) evaluate students’ perceptions of the fifth-year tutors. Method: Third-year students completed an anonymous survey pertaining to extracurricular clinical skills sessions. Results: Surveys were completed by 160 students of which 60% had attended at least one session. The most common reason for attending sessions was that they provided extra practice whereas those not attending most commonly stated that formal sessions were sufficient. All clinical skills topics and tutors were rated favorably. Conclusions: Whilst many students valued the need for clinical skills practice beyond formal class time, some students have yet to appreciate this. Extracurricular clinical skills sessions held by more advanced students were perceived positively irrespective of the topic taught. Thus near peer teaching sessions should be adopted by all medical schools.

Introduction Peer teaching, which involves a student teaching one or a few fellow students, is commonly used in educational settings, including medicine. There are several forms of peer teaching (also known as peer-assisted learning, peer tutoring, peer assessment) such as reciprocal peer teaching (also known as same-age, same-level teaching), near-peer teaching, and cross-age teaching (also known as cross-level teaching).1-5 Near-peer teaching is one of the more commonly used practices and involves a student who is more advanced in their studies, by at least one year, teaching less advanced students within the same course (e.g., fifth-year medical students teaching third-year medical students).1 The group sizes of students taught in a peer teaching arrangement can range from as few as one student (known as peer tutoring) to a relatively large group (e.g., a student giving a lecture).1 Peer teaching sessions can also be formal (e.g., compulsory attendance to a class taught by a

student) or informal (e.g., students teaching each other outside of formal class time).1 Several studies have examined students’ perceptions of peer teaching in a medical education setting. Within medicine, peer teaching has taken place in the context of students teaching others in a near peer context (i.e., students in the teaching role only being one year senior to the students in the learning role) and across year groups where students in the teaching role were more than one year advanced to students in the learning role as well as within numerous discipline areas within medicine such as anatomy, physiology and clinical skills.3-6 Within this paper we will predominantly review and focus on peer teaching within the context of clinical skills training. In Field and colleagues’ study, fourth- and fifth-year medical students taught clinical examination skills as a voluntary extracurricular activity to a self-selected group of first- and second-year students who later completed a survey regarding being taught by more advanced students.3,4 These students rated student tutors very favorable (e.g., being

Corresponding author: Christine McMenamin, Faculty of Medicine, Nursing & Health Sciences, Monash University Building 15, Clayton Campus, Clayton, Victoria 3800, Australia; Email: [email protected]


informed, providing useful feedback, and having clear explanations) and indicated that they would recommend the session to a friend.3,4 In another study in which attendance was also voluntary, first-year medical students were taught cardiac, respiratory, and blood physiology by third- and fourth-year medical students.6 These students also indicated that they were satisfied with being taught by more advanced students. In Silbert and Lake’s study, third-year medical students were given the opportunity to participate in voluntary clinical examination sessions held by fourth- to sixth-year medical students.7 During these sessions examination skills were practiced on real patients at a university affiliated tertiary teaching hospital. Students also rated these peer teaching sessions favorably (e.g., they found sessions relevant). Unlike a number of studies where medical students’ attendance was voluntary, Tolsgaard et al randomly assigned first-year medical students to be taught two clinical skills by either a trained student that was one or more years advanced or a clinical associate professor.3,4,6-8 Students were subsequently asked to rate nine statements regarding the teaching experience. There was no significant difference between the ratings by students who were taught by a student and those taught by a clinical associate professor with the exception of three ratings. For these three ratings student instructors were perceived more favorable. Favorable attitudes towards near-peer teaching is not the only positive attribute associated with this practice.3,4,6-8 Near-peer teaching is also favorably associated with students’ performance in assessments. For example, Jackson and Evans found that first-year medical students taught by third- and four-year students performed better on their exams on average than the previous cohort of first-year students who did not have near-peer tutors.6 In another study, Tolsgaard et al found that first-year medical students taught by more senior students performed equally well on a subsequent test to those taught by clinical skills teachers for one clinical task and performed significantly better for the other clinical task.8 Ten Cate et al examined the effects of being taught by near-peer tutors on a much larger scale than performance in individual units by examining exam performance over a five year period of students taught by faculty staff compared to those taught by near-peer sixth-year medical student tutors.9 Of the 36 courses in the study, results showed that mean exam performance of students taught by faculty staff members was higher for 5 courses whereas it was higher for students taught by sixth-year tutors for 29 courses.9

Peer teaching is not only beneficial to students in the learning role but it is also beneficial to students in the teaching role. Silbert and Lake found that medical student tutors had favorable perceptions of the peer teaching program in which they taught clinical examination skills to third-year students at a university affiliated tertiary teaching hospital.7 More specifically, these student tutors indicated that peer teaching increased their confidence in teaching and providing feedback, and increased their knowledge. In summary, previous studies show that students have positive attitudes towards being taught by near-peer tutors; and that being taught by a peer has positive consequences on their academic performance.3,4,6-9 In other words, near-peer tutors were just as effective and sometimes more so than paid professionals at teaching clinical skills. Furthermore, near-peer tutoring is not only beneficial to the student in the learning role but it is also beneficial to the student in the teaching role.7 Within the medical course at The University of Western Australia (UWA) fifth-year medical students offered an on-campus extracurricular peer tutoring service to third-year medical students. Three male fifth-year medical students acted as tutors in 2008 and were paid for their teaching. These tutors were specifically selected to act as tutors based on previous experience in teaching anatomy and having an outstanding academic record. The third year students’ attendance to the peer tutoring sessions was optional. These weekly sessions occurred outside of formal class time on a Wednesday at 5pm with the tutorial topic coinciding with the material formally taught during that week’s clinical skills session (e.g., cardiovascular, respiratory). There were three sessions per topic (e.g., three sessions on cardiovascular, three sessions on respiratory, etc.). At the end of each topic block students completed a summative assessment of the topic via an OSCE style examination during which students had to take a medical history and perform a physical examination pertinent to the topic. OSCEs were assessed by clinical academics. There was no summative end of year examination. Unlike, previous studies examining peer teaching in regards to students’ overall satisfaction with the practice and academic performance, our study particularly focused on why students attended / did not attend these voluntary extracurricular activities and whether some clinical skills topics are perceived to be more favorable than others.3,4,6-9 Thus the aims of the present study were to examine third-year medical students’ perceptions of the


extracurricular clinical skills peer teaching sessions offered by fifth-year medical students by: 1) enumerating the number of students that chose

to attend the extracurricular peer tutoring service (i.e., attend at least one session offered) along with their reasoning for attending or not attending; and

2) determining how useful students that attended at least one session found the service for different clinical skills topics.

Like previous studies, we also evaluated students’ perceptions of the fifth-year tutors.3,4 Method Participants All third-year medical students (N = 192) enrolled in the Foundations of Clinical Practice unit at UWA were asked to complete an anonymous survey regarding their perceptions of the extracurricular peer tutoring service offered by fifth-year medical students. Students were recruited at their summative assessment which followed the last clinical skills topic taught that year (end of October 2008). Procedure The present study was exempt from requiring formal ethics review from the Human Research Ethics Committee at UWA given that the project was of an evaluative nature in regards to teaching activities. Surveys were distributed to students while they waited in a waiting room for their clinical skills assessment. Clinical skills assessment sessions were conducted at various times over a consecutive three day period, with six students per session. Students were instructed that completion of the survey is voluntary and anonymous and that the return of the survey is taken as informed consent. A box for completed surveys was provided in the waiting room. Within the survey students were asked whether they were aware of the extracurricular peer teaching sessions offered by the fifth-year medical students. All students who were aware of the service were subsequently asked whether they had attended at least one of these sessions in the past and to provide a reason for attending/not attending. Only students who had attended at least one peer teaching session were instructed to complete the remainder of the survey. These students were asked

to indicate for which topic(s) out of seven topics they attended peer teaching sessions, whether they found the sessions useful in general and why/why not, and whether they would recommend the service to the next cohort of third-year medical students. Students were then instructed to complete 10cm visual analogue rating scales ranging from ‘not very useful’ to ‘very useful’ for each session topic that they had attended. Additionally, they were instructed to complete nine ratings regarding their general perception of fifth-year medical student tutors using 10cm visual analogue rating scales ranging from ‘strongly disagree’ to ‘strongly agree’ (see figure 1 for a list of the statements). At the end of the survey students were given the opportunity to suggest any improvements that could be made to the peer teaching sessions. Categories were created for all comments and were subsequently independently quantified by both authors. All discrepancies in categorizations were discussed until a decision was reached. Statistical analyses Frequencies of responses regarding awareness of sessions, attendance of sessions, topics attended, and comments made were calculated. Descriptive statistics were calculated for how useful students rated extracurricular clinical skills sessions for each topic that they had attended. A one-sample Wilcoxon Signed Rank Test was performed for ratings of statements pertaining to topics and tutors to determine whether median ratings significantly differed from the midpoint of the scale. Results One-hundred and sixty-three third-year students completed and returned the survey (i.e., a response rate of 85%). However, data analyses were only performed on 160 surveys because three students gave inconsistent responses (e.g., they indicated that they did not attend the peer teaching sessions but also rated the tutors) and thus these surveys were excluded. Not all questions were answered by all students. Attendance One-hundred and forty-three students indicated that they were aware of the peer teaching sessions. Sixteen students indicated that they were unaware of these sessions. Half of these students indicated that they probably would have attended if they knew about them. One student did not answer the question pertaining to awareness of sessions.


Figure 1. Third-year students’ mean ratings regarding their fifth-year student tutor(s). Negative statements are shaded in grey. SE bars are shown. Statements 1, 3 and 5 were adapted from UWA’s Students Perceptions of Teaching (SPOT) databank (questions can be accessed at http://www.catl.uwa.edu.au/etu/spot); statements 4 and 9 were adapted from Field et al (2004, 2007); statement 7 was adapted from Tolsgaard et al (2007); statements 2 and 6 were adapted from a combination of SPOT and Tolsgaard et al (2007); and statement 8 was adapted from a combination of SPOT and Field et al (2004, 2007). Note: 0 = strongly disagree; 10 = strongly agree Ninety-six of the 143 students who were aware of the peer teaching sessions reported that they had attended at least one session of the seven topics (number of topics attended: M = 4.0, SD = 2.1, range = 1-7). The most frequent reason given for attending peer teaching sessions was that they provided extra practise (see table 1 in Appendix). With the exception of comments classified as ‘other’ the most frequent reason given for not attending peer teaching sessions was that students thought formal sessions were enough (see table 1, Appendix). This was closely followed by not attending because of the time of day sessions were held and that students had work commitments at the same time. All students that attended at least one session indicated that they found them useful and that they would recommend them to the next cohort of third-

year medical students. The most frequent reason provided for why the sessions were useful pertained to some positive aspect regarding the fifth-year tutors who facilitated the sessions (see table 2 in Appendix). Topics The musculoskeletal topic was attended by the largest number of students whereas the respiratory and gastrointestinal topics were attended by the least number of students (see table 3). On average the sessions were rated very useful by students (see table 3). A one-sample Wilcoxon Signed Rank Test was performed to compare the median rating of each topic to determine whether ratings were significantly above the scale’s midpoint (i.e., a value of 5). All median ratings were significantly above the scale’s midpoint (all ps ≤ 0.05).

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Table 3. Descriptive statistics pertaining to the 10cm visual analogue scale third-year students completed in regards to how useful they found extracurricular clinical skills sessions for each topic ranging from ‘not very useful’ (0) to ‘very useful’ (10). N represents the number of students that rated the topic. Tutors Tutors were generally perceived favorably (see figure 1). A one-sample Wilcoxon Signed Rank Test was performed to compare the median rating of each statement to the midpoint value of the scale (5; i.e., neutral opinion) to determine if ratings significantly differed from a neutral option. All positive statements were significantly above the midpoint value whereas all negative statements were significantly below the midpoint value (all ps ≤ 0.05). Nineteen students suggested improvements that could be made to the peer teaching sessions. The majority of these students suggested that there should be more tutors because sessions were quite full or that sessions should also be held at different times. Discussion The aim of the present study was to examine third-year medical students’ perceptions of extracurricular clinical skills sessions offered by fifth-year medical students by: 1) enumerating students’ attendance; 2) examining ratings of clinical skills topics; and 3) examining students’ evaluations of tutors. Attendance We enumerated the number of third-year medical students who attended extracurricular clinical skills sessions offered by fifth-year medical students and evaluated their reasons for attending/not attending. Sixty-seven per cent of the third-year students that were aware of the peer teaching sessions indicated that they had attended at least one session. These findings suggest that students do attend such sessions even if attendance is optional and sessions are of an informal nature. The most common reason

stated for attending the peer teaching session(s) was that they provided extra practice. On the other hand, the most common reasons stated for not attending peer teaching sessions were associated with students feeling that formal sessions were enough, the time of day sessions were held (e.g., difficulty getting home, tired) or having work commitments at the same time. Students who indicated that they felt that formal sessions were sufficient have not yet understood that learning beyond what takes place in formal class time is required in order for them to master clinical skills training to become a good clinician in the future. Furthermore, these students have not yet realized the benefits they could obtain from extra teaching offered by students who are two years their senior. Thus explicitly advertising the usefulness of these sessions may encourage more students to attend. With regards to the time sessions were held it is possible that more students may attend such peer teaching sessions if they were held at more than one particular time and day of the week. Therefore it may be worthwhile canvassing students’ preferred session times at the start of each semester. All students that attended at least one peer teaching session indicated that they were useful and that they would recommend them to the next cohort of third-year medical students which is consistent with previous studies were peer teaching has been used. 3,4

Topics Attendance for the various topics ranged from 45 students attending the gastrointestinal and respiratory sessions up to 73 students attending musculoskeletal sessions. There was no pattern in terms of students attending extracurricular sessions for topics held at the start of the year (i.e., novelty effect of the sessions commencing) or at the end of the year. This could possibly be attributed to students having an OSCE style assessment following each block of topics taught instead of one final end of year OSCE covering all material taught throughout the year. Students rated peer teaching topics similarly in terms of how useful they were which suggests that peer teaching sessions are useful irrespective of the topic taught. Tutors The third-year students made positive comments regarding the tutors and rated them favorably, which replicates previous research showing that near-peer tutors are perceived positively.3,4 These findings suggest that engaging more advanced medical students to tutor less advanced medical students via extracurricular clinical skills sessions

Topic N M SDCardiovascular 55 8.8 1.2Chronic Illness 50 8.6 1.9Gastrointestinal 45 8.9 1.2Haematology/Thyroid 52 8.6 1.4Musculoskeletal 71 8.5 1.3Neurological 72 8.8 1.2Respiratory 45 8.9 1.3


can be advantageous for students in the learning role. Some students even noted that it was good to be taught by more advanced students as it gives them a students’ perspective in regards to what they need to learn. Conclusions Taken together the findings pertaining to attendance of extracurricular clinical skills sessions, ratings of topics, and ratings of tutors facilitating the sessions suggests that it would be useful to offer such informal extracurricular peer teaching sessions at all medical schools irrespective of the topics taught. It may also be beneficial to extend such an approach to all tertiary courses to enable students to practice and consolidate information they have learned during the week under the guidance of a more advanced student. In conclusion, the findings of the present study show that extracurricular peer teaching sessions offered by more advanced medical students are perceived favorably by less advanced medical students irrespective of the topic taught. These sessions are valuable in terms of enhancing medical students’ clinical skills. Acknowledgement This work was conducted whilst both authors were employed at the Discipline of General Practice, Faculty of Medicine, Nursing and Health Sciences, The University of Western Australia. Declaration of interest The authors report no declarations of interest. Keywords Medical students, student tutors, near-peer teaching, tutoring Notes on Contributors CHRISTINE McMENAMIN, is an adjunct professor, general practitioner, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia. NICOLE KOEHLER, is a lecturer in Assessment and Learning Design, Deakin Learning Futures, Deakin University, Melbourne, Victoria, Australia.

References 1. Ten Cate O, Durning S 2007, ‘Dimensions and

psychology of peer teaching in medical education’ Medical Teacher, vol. 29, pp. 546-552.

2. Krych AJ, March CN, Bryan RE, Peake BJ, Pawlina W, Carmichael SW 2005, ‘Reciprocal peer teaching: Students teaching students in the gross anatomy laboratory’ Clinical Anatomy, vol. 18, pp. 296-301.

3. Field M, Burke J, McAllister D, Lloyd D 2007, ‘Peer-assisted learning: a novel approach to clinical skills learning for medical students’, Medical Education, vol. 41, pp. 411-418.

4. Field M, Burke J, Llyod D, McAllister D 2004, ‘Peer-assisted learning in clinical examination’, The Lancet, vol. 363, pp. 490-491.

5. Lockspeiser TM, O’Sullivan P, Teherani A, Muller J 2008, ‘Understanding the experience of being taught by peers: The value of social and cognitive congruence’ Advances in Health and Sciences Education, vol. 13, pp. 361-372.

6. Jackson TA, Evans DJR 2012, ‘Can medical students teach? A near-peer-led teaching program for year 1 students’ Advances in Physiology Education, vol. 36, pp. 192-196.

7. Silbert B, Lake FR 2012, ‘Peer-assisted learning in teaching clinical examination to junior medical students’ Medical Teacher, vol. 34, pp. 392-397.

8. Tolsgaard MG, Gustafasson A, Rasmussen MB, Høiby P, Müller CG, Ringsted C 2007, ‘Student teachers can be as good as associate professors in teaching clinical skills’, Medical Teacher vol. 29, pp. 553-557.

9. Ten Cate O, van de Vorst I, van den Broek S 2012, ‘Academic achievement of students tutored by near-peers’ International Journal of Medical Education, vol. 3, pp. 6-13.


Appendix

Reasons N Example

For attending

Assessment preparation 5 "Attended a few to help for exam study."

Consolidation 6 "They were helpful for consolidating skills in clinical skills."

Extra practice 48 "Extra practice for clinical skills"

Not enough formal practise 4 "Insufficient practice time in FCP. Good teaching."

Obtain feedback 5 "Good chance to practice skills & get feedback / individual help."

One on one teaching 3 "Good practice. More 1 to 1 kinda [sic] teaching."

Revision 5 "Good revision for clin [clinical] skills"

Taught by students 6 "It helps to be taught by students who know the cirriculum [sic] of what you've learned"

To ask questions 5 "To go through all the examinations with experienced teachers, ask questions, learn things you didn't previously know about content/structure of exams."

Other 12 "It is good to be able to practice with other students"

For not attending

Formal sessions were enough 10 "Felt that clinical skills sessions were sufficient for practicing exams"

Late in day - tired, difficulty getting home

9 "I was usually too tired to go because they were late in the day (5pm)"

No time 5 "Didn't find the time"

Other commitments 3 "I had prior engagements on Wede [sic] nites [sic] (netball)."

Practise with others 5 "My boyfriend is in the same year and we do most of our practice together."

Work 9 "Worked at same time"

Other 11 "Anxiety in small groups"

Table 1. Reasons given for attending and not attending the extracurricular peer teaching sessions. Please note that some students gave more than one reason. Thus the number of comments does not correspond to the number of students surveyed. N represents the number of students that gave the reason stated.


Reason N Example Extra practise 23 "I got more practice! I learnt more."

Feedback 4 "Good information. Good feedback. Clarified skills needed."

Other 13 "Actual demonstrations of all tests, particularly special test"

Positive comment regarding tutors 28 "Very good tutors. Fun, friendly, knowledgeable."

Student perspective 11 "Good to have student perspective"

Tips 5 "Good to see a complete run through of the assessments. Helpful tips on how to remember everything."

To ask questions 8 "They provided good overviews and could ask them questions I thought of outside the clinical skills sessions"

To obtain extra information 4 "Provided extra information about exam."

Table 2. Reasons given for why extracurricular peer teaching sessions were perceived as useful. N represents the number of students that gave the reason stated.

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Students’ Attitudes towards Extracurricular Clinical Skills Peer Teaching Sessions