Peer teacher training (PTT) program for health professional students: interprofessional and flipped learning

Abstract

Background

The need for developing healthcare professional students’ peer teaching skills is widely acknowledged, and a number of discipline-based peer teacher training programs have been previously reported. However, a consensus on what a student peer teaching skills program across the health professions should entail, and the associated benefits and challenges, has not been previously described. The purpose of this study was to demonstrate the design and implementation of an interprofessional Peer Teacher Training (PTT) program, and explore outcomes and participant perceptions, using Experience-Based Learning (ExBL) theory.

Methods

In 2016, an interprofessional team of academics from across three healthcare faculties: Medicine, Pharmacy and Health Sciences, developed and implemented a six module, flipped learning, interprofessional PTT program. Pre- and post questionnaires, using a Likert scale of 1–5, as well as open ended questions, were distributed to students. Descriptive statistics were used to analyse quantitative data, and thematic analysis was used to analyse qualitative data.

Results

Ninety senior students from across the three faculties participated. Eighty nine percent of participants completed a pre- and post-course questionnaire. Students felt the required pre-class preparation, including online pre-reading, discussion board, videos, and teaching activities enhanced their face-to-face learning experience. In class, students valued the small-group activities, and the opportunities to practice their teaching skills with provision of feedback. Students reported increased confidence to plan and deliver peer teaching activities, and an increased awareness of the roles and responsibilities of health professionals outside of their own discipline, and use of different terminology and communication methods. Students’ suggestions for improving the PTT, included; less large group teaching; more online delivery of theory; and inclusion of a wider range of health professional disciplines.

Conclusion

The PTT program provided a theoretically informed framework where students could develop and practice their teaching skills, helping to shape students’ professional values as they assume peer teaching responsibilities and move towards healthcare practice. The flipped learning, interprofessional format was successful in developing students’ skills, competence and confidence in teaching, assessment, communication and feedback. Importantly, participation increased students’ awareness and understanding of the various roles of health professionals.

Background

The importance of developing teaching skills within the health professions is widely acknowledged, and a number of teacher training programs within disciplines of university healthcare education curricula have been previously described [1, 2]. There are four key reasons identified for developing the teaching skills of health professional students [2, 3]. These include 1) preparation for participation in peer teaching activities at university; 2) preparation for future roles as healthcare teachers in the workforce; 3) to assist in the development of communication skills, which may improve interaction with patients; and 4) to develop a better understanding of teaching strategies, which may in turn help students become better learners [1,2,3]. However, a consensus on what a student peer teaching skills program across the health professions should entail, and the associated benefits and challenges, has not been previously described or investigated. An opportunity to investigate these issues arose when we designed, implemented and evaluated an innovative peer teacher training program at the University of Sydney, that adopted an interprofessional and flipped classroom approach. The overall aims of the program were to: promote student engagement in the development of learning and teaching, assessment and feedback skills; and promote engagement with interprofessional education.

Interprofessional education in the peer teacher training context

Recent literature indicates that interprofessional education during healthcare training leads to improvements in leadership, collaboration and communication between healthcare teams, ultimately improving patient safety [4,5,6]. Although this link provides a powerful reason to implement interprofessional learning activities within university healthcare curricula, there are limited examples available [7, 8]. In fact, healthcare curricula have been described as “out-dated” and “static”, meaning graduates are “ill equipped” to work within increasingly complex healthcare systems [8]. Barriers to the implementation of interprofessional curricula within healthcare education include negative attitudes, with healthcare professionals preferring the silos of their individual disciplines; and pragmatic issues, such as the logistics of timetabling across disciplines.

It has been suggested that engagement in interprofessional learning activities within the senior years of university healthcare education, at a point in time when students have a well developed understanding of their own professional responsibilities, may assist in development of their professional identity [9]. Further to this, it is expected that by their senior years, students will have sound clinical knowledge and skills to draw on when teaching their junior peers.

The advantages of a flipped classroom approach

The flipped classroom approach promotes efficiency in learning, and the construction of knowledge through social interaction. It offers a pedagogical method where learners prepare for teaching by making themselves familiar with the material prior to class [10]. The advantages to this method include: 1) learners come to class prepared, with the same level of relevant information and knowledge, ready for application [10], 2) student engagement in activities is promoted through active learning sessions, as students spend in-class time applying knowledge and theory previously learnt, and 3) student motivation is increased, as they are accountable to each other for their contribution to activities [10]. Our program was planned to increase student knowledge and skills through pre-class preparation, followed by a face-to-face session, including small group activities, peer collaboration and formative assessment with feedback.

Theories that inform educational practice offer valuable lenses to assist in analysis of teaching and learning methods [11]. The Experience-Based Learning (ExBL) model developed by Dornan and colleagues (2014), suggests that medical student learning outcomes are acquired through participation in authentic activities, where resources are creatively used to construct ideal conditions for learning [12]. According to the ExBL model, students’ learning processes are fostered by three key areas of support:

• 1) Organisational; ensuring that the learning experience sits appropriately within the curriculum, with opportunities to participate in practice.

• 2) Pedagogic; is provided by teachers in the learning environment, including mentors, supervisors, and role models.

• 3) Affective; is provided by a warm and inclusive learning environment.

The purpose of this study was to demonstrate the design and implementation of an interprofessional PTT program, and explore outcomes and participant perceptions, using the ExBL model as a theoretical lens.

Methods

Course design

In 2016, at the time of the study there was no systematic preparation of students at our institution in interprofessional learning. An interprofessional team of academics from across three healthcare faculties: Medicine, Pharmacy and Health Sciences developed and implemented a flipped learning, interprofessional Peer Teacher Training (PTT) program. Designed within an interprofessional context, this unique program provides opportunities for healthcare students to develop skills in teaching, assessment and feedback, in preparation for peer assisted learning activities, and interprofessional practice as graduates. Delivered as a six module program (outlined in Table 1), participants were provided with theoretical background and opportunities for active participation in small group interprofessional learning teams. We focussed on using specific frameworks, such as Pendleton’s model [13] to give and receive feedback; Peyton’s four step approach [14] to teach a clinical skill, and ISBAR (Introduction, Situation, Background, Assessment, Recommendations) to effectively communicate clinical handover [15]. Importantly, formative assessment of teaching skills was woven throughout the program. The learning outcomes of the program are listed in Table 1.

Table 1 PTT program outcomes and modules

Facilitators

At each face-to-face session, a total of seven facilitators were present. We had a pool of trained facilitators to draw from for each session. Four academics from medicine, two from pharmacy, and two from allied health were available to lead facilitation. Additionally, four junior medical doctors and three final year medical students who had completed a teacher training program previously were available both to assist with facilitation of small group activities, and develop their own peer teaching skills. All facilitators were provided with a 1 h orientation session, and were provided with all teaching material prior to participation.

Mode of delivery

The PTT program used a flipped mode of delivery. Students had online access to all course material via the University’s learning management system. This included the content of each of the six modules, activities, and seven videos providing guidance on how to teach a skill; how to provide feedback; and how to teach small groups in the clinical setting. Students were required to complete module 1 online prior to attending a 1 day face- to- face class. The all day face-to-face teaching was a mixture of both small group (n = 3–4 students per group), and interactive, large group sessions. In total, we ran four face-to-face classes (n = 90).

Assessment and feedback

Formative assessments with feedback took place throughout the PTT program. Students were required to complete online tasks during module 1. In class, in their small groups, students presented a pre-prepared 5 min teaching session on a healthcare topic, and a 5 min skills teaching session on a non-healthcare topic (for example, making a paper boat), requiring pre-class preparation of approximately 2 h. These activities were formatively assessed using prepared marking rubrics during small group sessions, and students were provided with immediate feedback from the facilitator. Students were also required to provide formal feedback to their peers during these small group activities, and were formatively assessed on their ability to do so, and provided with constructive feedback. In their small groups, students also practiced clinical handover utilising ISBAR, using clinical scenarios. For example, a scenario where a speech pathologist, after assessing an in-patient to be at risk of aspiration, contacts the medical team to discuss the patient’s management plan.

Certificate of completion

At completion of the course, students received a certificate as evidence of formal training in teaching and assessment; plus a hard copy of all course content.

Study design

Recruitment

Senior students from the faculties of medicine, pharmacy and health sciences at the University of Sydney, were invited by email to take part in the PTT program. They were required to register online for the program.

Data collection and analysis

Pre and post-course questionnaires

Quantitative and qualitative data were collected from student participants by pre and post program questionnaires (see supplementary file to view the questionnaire). Unsurprisingly, there is no available, validated instrument for assessing our PTT program. Consequently, we generated our own questionnaire, based on three key themes we identified when designing the PTT program. The questions for students to reflect on were designed around these three themes, specifically:

• 1) Participants’ perceived ability with respect to the learning outcomes of each module, such as “I feel confident to provide constructive feedback to my peers.”

• 2) Participants’ intention to take part in future peer tutoring activities, such as “I am likely to volunteer to take part in formative peer assessment activities”.

• 3) Participants’ attitudes towards interprofessional learning were measured using questions from the Readiness for Interprofessional Learning Scale (RIPLS) [16]. For example; “Shared learning with other healthcare students as a student will help me to become a better team worker”.

The pre-course questionnaire was delivered online via LimeSurvey, and the post-course questionnaire was completed by students using a paper-survey at the end of the face-to-face class. Both closed and open-ended questions were used. For closed items, we used a five-point Likert scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (5). Quantitative data were analysed using descriptive statistics. The software package used was SPSS, version 22.

Participants were asked to respond to open ended questions pertaining to 1) the most useful aspects of the PTT program, 2) suggestions for improvement to the PTT program, 3) the positive and negative aspects of working with other health professional students. A thematic analysis of the qualitative data was performed [17] within each category. Data were coded and categorised into themes by the first and third authors (AB and CvD), and the data within each theme were quantified in order to measure thematic prevalence [17].

Ethics approval

The University of Sydney Human Research Ethics Committee approved the study. Written consent for participation was obtained from participants to enable us to include their data from this study.

Results

Registration and demographics

In total, 115 health professional students registered for the PTT program. Of the 115 students who registered for the PTT program, 90 (78%) successfully completed the PTT program. Thirty eight of these students (42%) were medical students, 34 (38%) were pharmacy students, and 18 (20%) were allied health students (physiotherapy and speech pathology). Thirty three of the students (37%) were male, and 57/90 (63%) were female. The median age was 23 years, and the range was 19–36 years.

Pre-course and post-course questionnaires

Of the 115 students who had registered for the program, all (100%) had completed an anonymous pre-course questionnaire. Of the 90 students who attended and completed the program, 80 (89%) completed the post-course questionnaire. The results of pre-and post-questionnaire are reported in Figs. 1, 2 and 3:

• 1) Student experiences of learning outcomes:

Fig. 1

Participants’ pre-course (N = 115) and post-course (N = 80) perception of Peer Teaching Training (PTT) program outcomes

Fig. 2

Participants’ pre-course (N = 115) and post-course (N = 80) students’ intention to participate in peer teaching activities

Fig. 3

Participants’ pre-course (N = 115) and post-course (N = 80) perception of their interprofessional learning

Student responses to questions regarding program outcomes (both pre-and post-course) are provided in Fig. 1. It is clear from the figure students reported vast improvements in their perceived competence and confidence in their understanding of educational theory, ability to carry out a short teaching session, ability to teach basic procedural skills, ability to assess, and ability to provide constructive feedback.

• 2) Student intentions to participate in peer teaching and preparedness to practice

Student responses to questions regarding their intention to participate in peer tutoring activities (both pre- and post-course) are provided in Fig. 2. Again it is clear from the figure that students reported a substantially increased likelihood of their intention to take part in peer tutoring and peer assessment activities at University, and an increased likelihood of intention to teach and assess students on entering the workforce. They also reported an increased confidence to teach students on entering the health professional workforce.

• 3) Student attitudes towards interprofessional learning:

Student responses to questions regarding attitudes towards interprofessional learning (both pre- and post-course) are provided in Fig. 3. It is clear from the figure that following participation in the PTT program, students reported a far more positive attitude towards interprofessional learning, and an increased awareness of interprofessional teamwork requirements.

Responses to open ended questions

Participant responses to open ended questions are displayed in Tables 2, 3 and 4. Qualitative data is presented within themes in each of these tables, with the data quantified to measure thematic prevalence [17]. Table 2 presents students’ perceived “Most useful aspects of the Peer Teacher Training Program”. In summary, the most useful aspects were perceived to be the models provided for teaching, feedback and communication (37/80, 46%); the small group activities, with provision of a safe environment for practice, self reflection and feedback (47/80, 59%); the content, resources and teaching methods (19/80, 24%); and the Interprofessional aspect of the program (20/80, 25%).

Table 2 Students’ perceived “most useful aspects” of the PTT program

Table 3 Suggestions for improvement to the “Peer Teacher Training” program

Table 4 Most positive and difficult aspects of working with other health professional students

Table 3 presents students’ “Suggestions for improvement to the Peer Teacher Training Program”. These included more theory to be delivered online to reduce face-to-face teaching time, and increase small group activities (30/80, 38%); the inclusion of more health disciplines, and a more diverse mix of students within small groups (16/80, 20%); and integration of the PTT program into the health professional curricula (10/80, 13%).

Table 4 presents both “The most positive and the most difficult aspects of working with other health professional students”. The most positive factors included gaining an understanding of the roles of multi-disciplinary team work and holistic patient care (24/80, 30%); developing interprofessional communication skills (18/80, 23%); and developing an understanding of various health discipline curricula and training. Over half of the students [45/80 (56%)] commented that there were no negative aspects to working with other health professional students. Difficult aspects included the various levels of knowledge and experience, and the desire for more time devoted to explaining the various roles (19/80, 24%).

Discussion

This study sought to explore factors in a flipped, interprofessional PTT program that enabled a diverse range of health professional students to simultaneously achieve key learning outcomes in educational theory and teaching skills, while developing and consolidating interprofessional practice, and their preparedness for peer teaching practice. Our findings showed that students were able to achieve the PTT program learning outcomes by demonstrating and having feedback on various aspects of key teaching competencies. Students felt prepared to practice as peer teachers, and many had undergone a change in attitudes toward interprofessional learning. As reflected in our results, students perceived the PTT program to be well aligned with their respective curriculum. The learning environment was enriched by a framework that allowed participants to prepare, practice and improve their newly acquired knowledge and skills in teaching, assessment and feedback within an interprofessional context. While there is some overlap, we now discuss the implications of our findings in the context of the three critical supports for Experience-Based Learning (ExBL): 1) Organisational, 2) Pedagogic, and 3) Affective.

Organisational support

Organisational support ensures student learning experience is aligned with curriculum outcomes, with opportunities for active participation [12]. A clear strength of the PTT program was its flipped learning format. Students felt the required pre-class preparation, including online pre-reading, discussion board, videos, and online activities enhanced their face-to-face learning experience, and promoted active participation. By using a Learning Management System, order and commitment were gained from students prior to class, as students became familiar with the required activities, assessment methods, and feedback techniques. Students felt the course content was relevant, with an appropriate depth and breadth of theory provided. They appreciated being able to attend a structured, formal class, with receipt of a certificate considered a valuable addition to their resume. Students felt that the program was well aligned with their respective curricula. However, development of teaching skills and provision of interprofessional activities were not otherwise provided at University. In fact, some students indicated a desire for wider opportunities for participation in the program, with 16/80 (20%) suggesting a greater range of healthcare professions be included. Some (10/80, 13%) suggested the program be embedded across healthcare curricula. In order to align with twenty-first century graduate requirements, there is a responsibility to ensure health professional students develop professionalism skills in both teaching and [18] and interprofessional teamwork [19].

Pedagogic support

Pedagogic support includes support for practice-based learning, which is provided by teachers in the learning environment [12]. Sixty percent of students in our study commented that provision of small group activities enhanced the achievement of their learning outcomes. The interactions of senior students from across the health professions, sharing their experiences, promoted collaborative student engagement. The small group activities required students to teach a skill, teach a medical topic, and provide feedback to peers. Evidence suggests that active learning opportunities that engage students provide a deeper understanding of knowledge, and aid knowledge retention [20, 21]. Our students appreciated the opportunity to model what they had learnt in theory. Students (37/80, 46%) reported the frameworks and models used in the PTT program, such as Pendleton’s model of feedback [13], Peyton’s four-step approach to teaching a skill [14] to be useful tools that will assist them in the future. In particular, they found ISBAR [15] for handover valuable in developing interprofessional communication skills, including the use of specific terminology. The PTT program facilitated students’ understanding of other health professions, helping to develop a more positive view of interprofessional learning. Students reported an increased understanding of how the individual roles of each health profession contribute to the function of multi-disciplinary teams, to provide holistic patient care.

Affective support

Affective support is provided by a warm and inclusive learning environment [12]. When students feel they are being treated as members of one community, with similar goals, a sense of belonging is fostered [22]. Students from a range of disciplines came to class prepared, with meaningful and manageable tasks that contributed to the learning of others in small group settings. The learning environment afforded by the facilitators promoted supportive and constructive interactions among group members that fostered students’ confidence in their teaching skills. Recent systematic reviews of teacher training programs for health professional students identified lack of participant assessment and feedback as a common deficit [1, 2]. However, in the PTT program, student learning was enhanced through multiple opportunities for practice with immediate feedback. By allowing students to provide and receive feedback, their responsibilities were aligned with their abilities, and competence and confidence was developed [23]. Students became active participants in developing their own skills in the relative “safety” of small groups. However, in addition to initial training, acquired skills require ongoing reinforcement and practice [3, 24]. Although students were provided with at least three small group activities, 30/80 (38%) expressed a desire for more of the educational theory to be delivered online, in order to provide additional opportunities for practice with feedback in small groups. Students’ comments are aligned with the recent trend towards the “flipped classroom” model, suggesting increased student satisfaction, engagement and learning outcomes [10].

Limitations

The strength of this study is that it is one of the first to demonstrate the feasibility and effectiveness of an interprofessional peer teacher training program. We acknowledge that the students who participated in the PTT program had voluntarily chosen to do so, which may have biased our results. We also acknowledge that our data collection instrument was purpose-built, with its reliability and validity being unknown. For reasons beyond our control, there was a high drop-out rate from those students who had registered (n = 115) compared to those who attended (n = 90). This large drop-out rate prevented us from carrying out any formal before-after statistical testing. Unfortunately we were unable to distinguish those 35 students who completed the pre-program questionnaire, but did not attend the program, or did not complete a post-program questionnaire, from the other 80 students. In our attempt to maximise student responses, and to gain honest responses from students, our data collection methods and tools had ensured all student responses to questionnaires remained anonymous, making it impossible to identify respondents or to match data. Since we have no information on the 25 students who dropped out between registration (pre-test) and the actual 1 day teaching session, we cannot test whether they differ from those who completed the course. Although it is possible they were systematically different from those who completed the course, we feel this is unlikely. Consequently, for the purposes of comparison we have simply assumed those who dropped out had similar pre-test results as the remainder. Thus, in Figs. 1, 2 and 3 we have used the data from all 115 in the pre-test results, and simply compared their results descriptively with the 80 who completed the course and supplied post-test data. However, we judged it inappropriate to perform formal statistical testing. This large drop-out rate also created difficulties with administration of the program. For example, it proved difficult to plan an equal distribution of students from the various disciplines within small and large groups. Although it would clearly consume the limited available face-to-face teaching time, to avoid this problem in the future, the pre-test should be performed only on those who attend on the day of teaching session. Alternatively, rather than making their responses anonymous, we could choose to de-identify responses.

Conclusion

The PTT program provided a framework where students could develop and practice their teaching skills, helping to shape students’ professional values as they assume peer teaching responsibilities and move towards healthcare practice, where inter-disciplinary team work is required [25]. Students from across three health faculties demonstrated a common interest in improving their teaching, assessment and feedback skills, and actively participated in the program. The flipped learning, interprofessional format was successful in developing students’ skills, competence and confidence in teaching, assessment, communication and feedback. Importantly, participation increased students’ awareness and understanding of the various roles of health professionals. The PTT program provided a dynamic tool to provide and shape opportunities for interprofessional activities, positively impacting on the culture of the health profession faculties at the University of Sydney. It is now our intention to widen participation and extend opportunities for practice.