Effectiveness of Peer-Assisted Learning in health professional education: a scoping review of systematic reviews | BMC Medical Education

Search results

This review identified a total of 3902 articles. After removing duplicates, we screened titles and abstracts of 3030 articles. Among these articles we conducted two rounds of review: the first was based on the title and abstract, and 39 were sought for retrieval. The second aimed to remove articles that did not meet the inclusion criteria by reading the full text. Ultimately, 24 systematic reviews were included in the scoping review. Figure 1 presents the flowchart of the screening process according to PRISMA guidelines. Supplementary file 2 provides the references of excluded papers and the reasons for their exclusion.

PRISMA identification and screening process

Characteristics of selected systematic reviews

The main characteristics of the included systematic reviews (SRs) are summarized in Table 1. The 24 included SRs were conducted across twelve countries, namely Australia (n = 6), the UK (n = 5), Singapore (n = 4), the USA (n = 1), Chile (n = 1), India (n = 1), Indonesia (n = 1), Malaysia (n = 1), New Zealand (n = 1), Norway (n = 1), the Republic of Korea (n = 1), and the United Arab Emirates (n = 1). In terms of participants, medical, nursing, dentistry, mental health, physician assistant, and pathology students were included. Meta-analysis was used in nine SRs to calculate the combined effects of PAL in health professional students. 18 SRs summarized the effectiveness of PAL through narrative synthesis, with three using thematic analysis, one meta-synthesis, and one meta-aggregation. The systematic reviews included 423 primary studies published between 1975 and 2021.

Regarding methodological quality, the included reviews ranged from medium to high quality (see Table 2) according to the JBI quality appraisal tool (range 5–11). All reviews clearly stated the research question and had appropriate inclusion-exclusion. However, most reviews lacked methods to minimize errors in data extraction (criterion 7), assessment of publication bias (criterion 9), and recommendations for policy and/or practice supported by the reported data (criterion 10).

Evaluation of PAL in health professional education

The evaluation of PAL in health professional education was synthesized under the Context, Input, Process, and Product respectively. The PAL implementation context included three aspects.The Input components focused on tutors recruitment and tutors training. The Process evaluation encompassed PAL categories and PAL activities. Outcomes of PAL were summarized from the impact on peer tutors, peer tutees, and health professional educators, as well as the challenges of PAL. (See Fig. 2)

Application of PAL in health professional education

Context evaluation of PAL

Only two reviews evaluated the context of PAL implementation [33, 48]. The development of PAL were driven by three main reasons: literature support for the theory, problem-based drivers such as staff resource issues, and the need to enhance the teaching and assessment skills of students.

Input evaluation of PAL

PAL inputs focused on tutors recruitment and tutors training. The selection process for peer tutors considered their experience, motivation, academic level, and leadership qualities [33, 36, 39, 48]. Mentor training included basic principles of teaching, specific content, and practical skills [14, 19, 33, 36, 39, 41, 48, 49].

Process evaluation of PAL

The common features of PAL, such as PAL categories, activities, group size, and frequency, are detailed in Table 3.

Implementation of PAL could be categorized as same-level PAL [10, 19, 33, 35, 36, 38, 41, 45, 46, 48] and near-peer teaching [10, 14, 17, 19, 32, 33, 35, 36, 39,40,41, 45, 47, 48].

Twenty reviews (83.33%) reflected a wide range of PAL implementation strategies, including curriculum design [48], peer teaching [10, 14, 19, 33, 35, 36, 40, 44, 46, 48], peer tutoring (mentoring) [14, 17, 32, 35, 36, 42, 48], peer feedback [19, 20, 33, 41, 46, 49], peer simulation [19, 35,36,37, 40, 46], peer discussion [19, 36, 40, 46, 48], peer-led debriefing [35] and peer supervisor [10, 35].

Four reviews [10, 32, 47, 48] reported the group size of PAL, ranging from 1 to 25 students per group. Four reviews [10, 47,48,49] described the duration of each session of PAL, which ranged from 15 min to 6 h. And two reviews [47, 48] reviewed the frequency of PAL as 1 to 26 sessions.

Product evaluation of PAL

Outcomes of PAL were reported under the following headings based on peer tutees, peer tutors, health professional educators, and challenges of PAL. A summary of evidence was shown in Supplementary file 3.

Outcomes of peer tutees

Twenty-one reviews (87.5%) evaluated the effect of PAL on tutees. Findings were categorized into reaction, learning, and behavior according to Kirkpatrick’s evaluation model.

Regarding their reactions to PAL, participants perceived a more supportive and low-threat learning environment [36, 40, 46], and gained support when connecting with peers [34, 43, 46], which made them feel more comfortable, relaxed, engaged, and prepared for future evaluation [20, 36, 40, 42]. They believed that PAL was a more effective and valuable method [36, 37]. However, mixed effects were found on their satisfaction and team dynamics [40, 41, 45, 49].

The learning outcomes were reported in 20 SRs and were divided into four subthemes: knowledge, attitude, skills, and mental health. Peer tutees reported positive outcomes such as enhanced knowledge, higher scores, and a deeper understanding of the content [14, 18, 34,35,36, 38, 43, 45]. Higher self-efficacy was found among peer tutees. They increased their motivation to participate, gained confidence, and reported greater learning opportunities, as well as a continued understanding of their development [34, 36, 37, 43, 45, 46, 49]. What’s more, they improved their skills after the PAL program, including communication, empathy, procedural, technical, problem-solving, teaching, clinical, teamwork, leadership, reflection, judgment, and other skills [10, 32, 34, 37, 38, 41, 43, 45, 46]. In the field of mental health, PAL was beneficial in reducing stress and anxiety [32, 34, 36, 42, 45]. However, ambiguous effects were shown on some learning outcomes, such as learning scores, learning opportunities, skill scores, and stress levels [10, 19, 36, 37, 39,40,41,42, 44,45,46, 48, 49].

Two SRs reported positive behavior changes. They showed increased collegial behavior among nursing students [45] and a tendency to use active coping mechanisms after the program [42].

Outcomes of peer tutors

Nine reviews (37.5%) evaluated the effects of PAL on peer tutors. The outcomes were categorized into reaction, learning, and behavior based on Kirkpatrick’s evaluation model.

Peer tutors involved in PAL perceived a more relaxed environment and experienced enjoyment during the process [20, 33].

For the learning outcomes, peer tutors gained a more profound understanding of knowledge, encompassing both subject-specific and pedagogical knowledge [20, 33, 36, 40, 47]. They developed self-confidence and had greater courage, motivation, and autonomy to teach and learn [20, 33, 36, 40, 42, 47]. Peer tutors also improved various skills after the PAL program, such as teaching skills, leadership qualities, communication ability, empathy, ability to admit uncertainty, time management, and teamwork capacity [17, 20, 32, 33, 36, 40, 42, 47]. Conflicting results were presented in two reviews about their learning outcomes and scores [33, 48]. For example, two original studies in the Burgess’ review evaluated peer tutors’ learning scores. The findings of one study showed that peer tutors achieved significantly higher scores, however, the results of the other study showed no benefit to tutors knowledge acquisition.

Finally, positive behavioral changes were reported in one review [32].

Outcomes of health professional educators

Only a few reviews reported the effect of PAL on clinician educators. Tai [46] observed that PAL did not reduce the time of clinical educators but did result in more satisfying educational interaction and contributed to the development of educational skills, such as giving feedback.

Challenges of PAL

Ten reviews (41.67%) assessed the issues and adverse effects associated with PAL, including unpleasant experiences, inadequate competence of peer tutors, and even conflicts.

PAL was perceived as a “significant change” in the learning experience, initially inducing anxiety among students. Some students were unclear about the purpose of PAL and felt that the change was imposed without adequate preparation, leading to anxiety. The lack of training in the peer education program also raised concerns among participants. Additionally, students experienced unpleasant emotions such as stress, fear, and embarrassment when criticized or judged by their friends [20, 33, 34, 38, 40, 41, 49].

The competence of peer tutors was questioned due to the lack of necessary professional knowledge, skills, experience, and authority [38, 40, 46,47,48,49]. It was noted that peer feedback and assessment were often inconsistent with the judgments of other experts on performance [20, 33, 46]. In addition, students may refuse to participate in the evaluation or provide overly positive feedback due to fear of facing criticism and a desire to avoid low scores [20, 38, 46].

Moreover, Secomb [45] demonstrated that conflicts arose when students were incompatible due to differences in their knowledge levels, educational backgrounds, or incompatible personalities.