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ORIGINAL ARTICLE
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Peer-assisted learning versus faculty led learning in procedural skill acquisition utilizing skills laboratory


1 Department of Microbiology, Government Medical College, Kozhikode, Kerala, India
2 Department of Social and Preventive Medicine, Government Medical College, Manjeri, Kerala, India
3 Department of Microbiology, Government Medical College, Manjeri, Kerala, India

Date of Submission21-Oct-2019
Date of Decision20-Sep-2020
Date of Acceptance25-Sep-2020

Correspondence Address:
Kalpana George,
Department of Microbiology, Government Medical College, Kozhikode, Kerala
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_284_19

  Abstract 


Background: The aims of this study were to compare the outcomes of faculty led learning with peer assisted learning in acquiring procedural skills and to analyze perceptions on the learning experience of both groups so that feasibility of adopting peer teaching can be considered in the skills laboratory. Methods: Medical students from 4th semester were divided into two groups – A - Individual learners and B - peer tutored students. Group A was taught bladder catheterization by faculty. Six volunteers were chosen as peer teachers, trained by faculty to perform and teach the procedure. Each peer teacher was assessed for training skills. Five to six students were then assigned to each peer teacher. At the end of the study period, each student was assessed for skills acquired by objective structured practical examination. Feedback from students on perceptions of their learning experience was collected using validated feedback instrument. Results: Fifty-seven students excluding peer teachers were assessed–30 in Group A and 27 in Group B. Mean competency scores of Group B was higher than those of Group A (P < 0.012). Median scores of perceptions on overall skill development, teacher contribution, and student satisfaction were not different between the groups. Conclusion: This study has demonstrated that peer teaching can be an effective and feasible tool to teach basic procedural skills to students. Perceptions on the learning experiences of individual and peer led groups in the skills laboratory were not different emphasizing the acceptability of the peer tutor approach.

Keywords: Peer-assisted learning, peer teachers, peer tutoring, procedural skills, skills laboratory



How to cite this URL:
George K, Rahim A, Moorkoth AP, Pangat Balakrishnan SM. Peer-assisted learning versus faculty led learning in procedural skill acquisition utilizing skills laboratory. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Jun 13]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=316412




  Introduction Top


Changing times dictate innovative approaches to the delivery of medical education. The benefits of alternatives to traditional teaching including peer-assisted methods are well established.[1],[2],[3] Peer tutors have been perceived as surrogate teachers, but it is increasingly being recognized that peer tutoring interaction is qualitatively different.[4] It has been shown that peer assisted learning (PAL) has positive influence on the students' learning experience.[5] Peer tutors are usually fellow students whose knowledge do not compare with that of faculty and they usually have little teaching experience.[6] Peer learning can be defined as the acquisition of knowledge and skills through active help and support among status equals or matched companions.[7] Medical educators support peer teaching because it imparts team building skills and helps to identify an individual's own strengths and weaknesses.[1] Advocating peer teaching is considered by some researchers as a potential means on reducing teaching pressure on faculty.[6],[8],[9] The peer teachers share a “cognitive congruence” with the peer tutees.[8],[10] They are able to communicate with their tutees more effectively, thereby improving the learning environment. The other advantage is that the tutor's competence also increases with the development of teaching skills.[11] Students involved in peer teaching have an opportunity to understand teaching-learning principles thereby making them better learners.[3]

Skills laboratories are ideal settings to experiment and generate evidence on the effectiveness of innovative teaching learning methods, such as cooperative learning, collaborative learning, and PAL. Historically, clinical skills, including basic procedural skills were learned through observing different procedures for a certain period or a set number, followed by performing the same procedure under supervision. Skills laboratory is a “mistake forgiving” training environment were skills can be taught in a standardized manner.[12] In addition the assessment of knowledge and skill acquisition can be performed uniformly in the lab.[13] Although skill labs have an established role in medical education worldwide, it is yet to find wide deployment in India.[14],[15]

Peer teaching or PAL with its documented advantages can be employed to teach psychomotor skills as well. Preece and Beard have been able to demonstrate that surgical skills can be taught effectively to medical students by peers.[16],[17] Adequately supervised peer tutoring can be adopted as a mode for teaching clinical skills in the skills laboratory.[18]

There is no data from India on utilizing peer teachers to teach procedural skills. This study was aimed to compare procedural skill acquisition through faculty led learning with that of PAL. Perceptions on learning experiences of both groups in the skills lab were analyzed, thereby exploring the feasibility of PAL in acquiring a simple procedural skill.

We hypothesized that basic procedural skills are learnt better through peers-assisted learning compared to faculty assisted learning.


  Methods Top


Participant selection and methodology

A quasi-experimental study was conducted at Government Medical College, Kozhikode, after obtaining Institutional Research Board clearance (IRB Ref: IRC/2016/Protocol/108 dated July 12, 2016). Consenting medical students from 4th semester MBBS batch were included in the study.

Sample size for the study was calculated using standard deviations (SDs) and effect size from a study on PAL by Han, Chung and Nam et al., where the SDs for the two groups were 16.87 and 16.76, respectively, and the effect size was noted to be 5.[19] Based on this 13 students were required in each group.

Participants were selected by random sampling from class roll. They were divided into faculty led Group A (odd numbers) and peer led Group B (even numbers) of 30 students each to study the learning outcomes of two instructional approaches to teach procedural skills. The duration of the study was 3 months. The skill selected for instruction was insertion of indwelling bladder catheter. Students who had any kind of prior exposure to bladder catheterization were excluded from the study.

Group A was taught bladder catheterization by a single faculty member over a period of 6 days. Each day a group of 5 students were taught the procedure by modified Peyton's four step approach.[20] Emphasize was given to other key components of technical skills including aseptic precautions, communication, and team work.

To start with six volunteers were chosen from the same batch who were good communicators as peer teachers and were trained by faculty on the key components.[21] Each peer teacher was assessed individually for training competence using a validated checklist. It was decided that the peer teachers should get a score of 16 which was the maximum possible score with the checklist. Five students from Group B were assigned to each competent peer teacher. Peer teachers taught the procedure to their assigned tutees by modified Peyton's four step approach as was carried out for Group A by faculty.

Students in Group A were encouraged to visit the skills laboratory individually during the study period. They were allowed to perform catheterization on manikins under faculty supervision. After the initial teaching session by peer teachers, students in Group B were asked to attend practice sessions as a group along with peer teachers. During these sessions, faculty was present as silent observers.

Designing the training module

Faculty/peer teacher first gave power point presentation on indications for bladder catheterization, risks involved, types, and sizes of catheters that are used and care of catheter. A high quality video on bladder catheterization followed the lecture.

Modified Peyton's four step approach was used to design the skill training module.[20]

  1. Demonstration and deconstruction-faculty/peer teacher demonstrates bladder catheterization on a mannequin following all aseptic precautions at normal pace without any comments and repeats the procedure once again describing all necessary steps. This included obtaining a consent also
  2. Comprehension, tutor's performance and observation-faculty/peer teacher repeats the procedure on mannequin following instructions of trainee 1, while all other trainees are watching
  3. Comprehension, trainee's performance, and observation-trainee 1 does the procedure following instructions of trainee 2, while all other trainees are watching
  4. Tutor and peer feedback-trainee 1 receives feedback by peer trainees followed by tutor feedback.


Faculty trained a group of 5/6 students during a given session. Peer teacher trained his/her assigned group of students.

Evaluation of skill

At the end of the study period each student was assessed for skills acquired by objective structured practical examination (OSPE) using validated checklist (Cronbach's α score of >0.7) [Annexure 1]. Maximum score that could be attained was 16. Students who did not achieve a score of 13 (<80% score) were given remedial sessions by the faculty and reassessed.

Feedback from tutees on perceptions of their learning experience was collected using a validated feedback instrument [Annexure 2]. The perceptions of groups on (1) skill development (2) teacher contribution and (3) overall student satisfaction were measured on a four-point Likert scale. For Group A and Group B, perceptions on teacher contribution related to the faculty and peer teacher respectively were collected. Feedback was not collected from peer tutors.

An open-ended question was asked in the feedback-form regarding difficulties that were encountered in accessing skills laboratory during the study period and also about the ease of using the facilities in the laboratory. The aim was to make necessary changes according to the requirements of students.

Data analysis

Statistical analysis was done using Epi infoTM Version 7.2, CDC, Atlanta, Georgia. The mean scores of OSPE were compared using independent t-test. Mann–Whitney U-test was used to compare the median scores of perceptions.


  Results Top


A total of 60 students enrolled for the study. This corresponds to 25.4% of total 4th semester students. Fifty-seven students excluding peer teachers were assessed – 30 in Group A (faculty led) and 27 in Group B (peer led). Three students who did not attend the practice sessions were excluded from assessment. The response rate was 95%. The mean number of practice sessions attended by the entire cohort was 1.56 (SD 0.76). There was no significant difference in the number of practice sessions attended by the two groups (Group A 1.60, SD 0.77 and Group B was 1.52, SD 0.75).

Of the 30 students from Group A, five students (16.6%) achieved scores equal to or above 13, whereas 12 students (44.4%) from Group B achieved the same. Mean competency scores of Group B (12.3, SD 1.95) was higher than Group A (10.9, SD 1.97) and this was found to be statistically significant (P < 0.012) [Figure 1].
Figure 1: Mean competency scores –faculty led versus peer led group

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Median scores of perceptions obtained on overall skill development [Figure 2], teacher contribution [Figure 3] and student satisfaction [Figure 4] were not different between the groups.
Figure 2: Median scores- perceptions on skill development

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Figure 3: Median scores- perceptions on teacher contribution

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Figure 4: Median scores – perceptions of students' satisfaction

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Twenty-three (76.6%) students from Group A and 25 (92.5%) from Group B responded to the open-ended questions. The most commonly raised concern was the conflict in the work hours of the skills laboratory with the routine academic activity. A second issue raised was the nonavailability of adequate numbers of manikins. Sixteen students from Group B noted that there was difficulty in arranging a suitable time for all the peer group members to attend the training sessions together as they were instructed to do so. 73.4% of students thought that the number of practice sessions attended by them is adequate for them to carry out the procedure on a real patient.


  Discussion Top


The study was aimed at evaluating procedural skills acquisition through PAL compared to faculty led learning. The analysis of learning experience thorough PAL thereby investigating the feasibility of PAL in procedural skills acquisition was planned too. A gap was identified in the effective utilization of skills laboratory in this study. Bladder catheterization was selected for instruction as it is an essential procedural skill that needs to be acquired by any medical student. Emphasize was given to consent taking, ensuring privacy of the patient, hand washing techniques, and maintenance of asepsis apart from the procedure itself.

The study has demonstrated that simple procedural skills can be taught effectively by peer teachers as evidenced by the better performance of the PAL group. Peer-assisted learners achieved higher mean competency scores in OSPE compared to students taught by faculty. That the peer led group was not at a disadvantage compared to faculty led group is in agreement with other studies that compared peer assisted teaching with traditional teaching in imparting procedural skills.[11],[18],[22],[23],[24] The higher competence scores achieved by peer led groups could be a function of the low anxiety and stress levels of students.[23] Few studies have failed to demonstrate benefit in terms of examination performance by peer led groups compared to faculty led groups.[22],[25],[26] Students who scored <13 out of 16 (which roughly corresponds to more than 80%) were given remedial classes by faculty and reassessed for achievement of competence. Even though the mean competency scores of PAL assisted group was significantly higher than faculty led group, <50% of them achieved scores above 13.This could be attributed to inadequacy of the number of practice sessions attended. The mean number of practice session attended by the entire group was 1.56 (SD 0.76), which was not very different from that of individual groups. The students have pointed out few reasons for not attending the practice sessions.

In resource scarce settings, PAL systems may be utilized by medical schools to deploy resources more effectively.[6],[27],[28] The skills laboratory facility in our institute was not being utilized optimally due to faculty shortage. With the promising results generated, we have extended peer training in skills lab to subsequent batches of medical students including more basic. Two dedicated faculty are also posted in the skills laboratory. Authors believe that monitoring of the process is essential to maintain standards and uniformity of teaching.

In PAL, both tutors and tutees are benefitted. The perceived benefits of peer tutors include a sense of personal reward, consolidation of knowledge and development of skills in teaching and learning.[1] PAL may be viewed as a means to provide additional student support.[24] We did not document the perceptions of teaching experiences or the learning outcomes of peer teachers as they were only six in number.

Perceptions of students on satisfaction of the skills lab experience and skill development were similar between the two study groups. Although satisfaction in both groups was similar, peer led group had higher performance scores. This could be explained by the fact, that students in Group B were asked to attend practice sessions as a group along with peer teachers, in a stress free, nonthreatening environment, focusing on cooperative learning, as compared to faculty led training. Teacher's (faculty/peer teacher) contribution to learning was also not perceived to be significantly different by the two groups. This emphasizes the acceptability of PAL by students. Mills et al., in their study have demonstrated that there was no significant difference in terms of student satisfaction whether taught by peers or faculty.[27] Tolsgaard et al. analyzed student learning experience when taught by student teachers compared to associate professors in a randomized control trial. They included two skills for teaching and concluded that learners were more satisfied with student tutors.[24]

There were three dropouts from the PAL group. Peer tutees were allowed to practice the procedure only as a group along with peer teachers. Due to conflict in time schedule of various regular clinical rotations, three students could not attend the practice sessions along with the peer teacher.

A motivated group of peer tutors is important for a successful outcome of the program. Learners would benefit from enthusiastic, motivated peer teachers.[29] It is important to remember that the strength of a peer teaching program depends on the quality of peer teachers. Peer teachers should be competent in the selected practical skill before sessions are started. It is equally important to train them for their roles as teachers as this will increase confidence in imparting skills.[1],[11] In the current study, the peer tutors were recruited based on their expressed interest to teach their peers. The selected peer teachers were trained and were assessed individually for their teaching skills. Well-trained enthusiastic peer teachers would have contributed to the success of the program. For any peer based teaching program, faculty should remain vigilant to prevent inconsistencies developing in delivery of knowledge.[30]

Limitations

Only one skill was taught and assessed. Though the study was adequately powered to note differences between groups a larger cohort would yield stronger associations.


  Conclusion Top


The mean competency scores of peer led group were higher than faculty led group which was found to be statistically significant. Perceptions on the learning experiences of both groups in the skills lab were not different. This study has demonstrated that peer teaching can be an effective and feasible tool to teach basic procedural skills to students.

Acknowledgment

Skills and Simulation Lab, Regional Centre for Medical Education Techniques, Government Medical College, Kozhikode. Nodal Centre for Faculty Development, Medical Council of India, Government Medical College, Kottayam, Kerala, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Annexures Top


Annexure 1: OSPE Checklist

Student name_______________Date:

Skill Station: Indwelling bladder catheterization

You are taking care of a patient in medical ward. Patient complains of pain abdomen.

On examination (per abdomen), bladder palpable. You decide to catheterize the patient.

Demonstrate the procedure on a manikin.

Observation: Observe if the participant is performing the following steps of catheterization in their correct sequence (as necessary) and technique.

Score “1” for each point conducted correctly, ½ marks for partially correct task or mark “0” if the task is not done or incorrectly done and calculate the score. You will be provided with an assistant.







 
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