Peer learning in the clinical setting
Storrar, Neill Peter Forbes
Qualified doctors must work and learn together. Peer learning - where students at a similar level teach one another - seems well suited to achieving these complementary goals of competence and collaboration. Peer learning is widely practised in medical education particularly in the classroom and skills laboratory, but there is less evidence for its use in the setting of wards and clinics where much of medical training takes place. While studies do report peer learning in the clinical arena, there remain unanswered questions about its measurable impact on performance – is peer learning effective in the clinical setting? There is also a gap in the understanding of its impact on peer relations. Critically, while many advocates of peer learning have emphasised its social benefits, others have highlighted risks to students for example through development of unhealthy competition. This leads many students to be unwilling to engage in peer learning at all. These conflicts are not well covered in current theoretical models of peer learning in medical education. We therefore do not have a clear understanding of the practical benefits of peer learning in the clinical setting, or how students respond to the potential conflicts involved in peer interaction. This thesis tests whether peer learning in the clinical setting leads to gains in ability, and explores the contradictory pressures that govern student decision making about peer learning. It is structured as follows. In Chapter One the concept peer learning is introduced and its role in the clinical setting is briefly surveyed. The theoretical framework of the thesis – Pragmatism – is defended, and is followed by a discussion on methodology. In Chapter Two a published paper is presented based on students’ general priorities in medical education. This confirms the plausibility of peer learning in the clinical setting, and demonstrates the author’s development of key research skills. Chapter Three the way students resolve potential conflicts in peer learning is explored. Using Classic Grounded Theory – an established method of theory generation – the novel theory of ‘Internal Negotiation’ is explained. The theory predicts how students will balance educational and social pressures when making decisions about engagement with peer learning. This is followed by a discussion of the theory’s place in the wider literature and its practical implications for those interested in improving peer learning projects. Chapter Four presents the results of project testing the impact of a peer learning project in the clinical setting. The project – dubbed Peer Practice – was intended to promote abilities in basic consultation skills. The literature review highlighted a major gap in the evidence for peer learning’s impact on performance in the clinical setting. The effect of Peer Practice was tested through the lens of the ‘practical trial’ using experimental cross-over type design to answer questions about performance gain, impact on students’ view of peer learning, peer learning’s acceptability and other measures. A small performance benefit from Peer Practice was demonstrated, and the consequences for future work are discussed. Chapter Five integrates the lessons of the preceding chapters. In summary the thesis has developed a new and plausible theory of peer learning and how students negotiate social and educational tensions when choosing whether to take part; it has presented a rigorously designed experimental study of peer learning in the clinical setting and demonstrated modest performance gains amongst other benefits. It has thus added to the knowledge of peer learning in medical education and drawn lessons for those interested in promoting clinical competence through the use of collaborative activities in the clinical setting.