Informal peer‐assisted learning amongst medical students: A qualitative perspective

Peer‐assisted learning (PAL) can occur informally as part of a medical programme and complements the formal curriculum. However, little is known about the mechanisms and processes of how informal peer‐assisted learning (IPAL) is enacted.


| INTRODUCTION
The formal concept of peer-assisted learning (PAL) is an educational concept that prescribes a formal teaching contribution of student peers within a wider learning environment.PAL has been shown as beneficial in terms of knowledge both transmitted and reinforced from elsewhere on a course. 1 It can lead to improvements in reflective practice, confidence in subject matter knowledge, problem solving and responsibility for the ongoing development of the peer group. 2 Systematic review evidence shows PAL has a positive impact improving the performance of medical students academically. 3Meta-analysis has shown that PAL is not inferior as a learning modality to teaching by faculty educators. 4Examples of formal PAL in undergraduate medicine include anatomy, 5,6 pathology, 7 clinical examination teaching, 8,9 cannulation, 10 elementary surgical skills, 11,12 aspects of pharmacology 13 and simulated accident and emergency cases. 14In postgraduate medicine, PAL has been applied to surgical techniques 15 and evidence-based medicine. 16ilst formal PAL has benefits widely described in the literature, less is known about the mechanisms and benefits of informal PAL (IPAL).There is evidence that IPAL happens frequently, through medical student social networks, 17,18 and can have a beneficial effect on learning 19 and psychological wellness. 20,21Social learning happens in medical education when informal groups form amongst formally allocated group peers or friends from the course in order to study.Such groups would consist of 2 or more students and would share knowledge. 22Informal study groups can also form amongst friends as offshoots from a PBL-based environment. 23Informal peer support can also occur during clinical studies away from the clinical area. 24,25In the United States, an attempt to provide continuity over a 6 to 12 month period on a medical course has resulted in peer groups that gave each other formal and informal support with learning in a way that was easier to access than in the more traditional block placements. 26Little is known about how IPAL is enacted or its outcomes for learners.
Little is known about how IPAL is enacted or its outcomes for learners.
One key social learning theory that helps explain formal and informal peer support is 'legitimate peripheral participation'. 27,28During a programme of learning, many situations arise where knowledge and skills can be acquired by participating within a group through 'communities of practice', which include learners and people with experience in the activity at hand.Enquiry-based learning in small groups provides opportunities for peer support: For example, a focus group study of communities of practice amongst UK graduate entry medical students found them correcting each other and sharing resources. 29 relation to integration, 30 the current study as part of a wider PhD thesis aimed to investigate the areas where IPAL proves beneficial, through ethnographic observation and in-depth interviews.Our findings help fill the gap between theoretical benefits of IPAL and the mechanisms and processes through which IPAL is enacted.

| Study design
Ethnographic observation of two groups of 12 early years undergraduate medical students was followed by semi-structured interviews with medical students and staff members.The wider PhD study sought to explore experiences and views of integration in a UK medical school undergraduate programme and was approved by the University Research Ethics Committee (ref 14255).

| Context
On this particular medical programme, students undertake enquirybased learning through problem-based learning (PBL) in groups of 10-12 students.The first 2 years are divided into four semesters, with the students forming new groups each semester.Learning takes place through a range of classes including PBL, lectures, practicals, anatomy classes and skills sessions.

Ethnography
Two PBL groups (one Year 1, one Year 2), with 12 students in each, were recruited.Both groups primarily contained school leavers, with a minority of mature students.Most were home students; a minor proportion were international students.The students were observed in a range of learning contexts.

Student interviews
The students in both PBL groups were invited for interview following the observation period.Seven out of 12 in Year 1 and five out of 12 in year 2 agreed to be interviewed (12 overall).

Staff interviews
Sixteen medical school staff were interviewed (20 were initially invited).They were involved in PBL, consultation skills, physiology and pharmacology, anatomy, evidence-based medicine, personal and professional development, early clinical experience visits and assessments.Some had senior leadership roles on the medical programme.

| Data collection
Ethnography with semi-structured interviews were the chosen methods of data collection.Observational research has the ability to capture IPAL as it actually happens during student interaction on the medical course.This is complemented by the interviews, which allow the student perspective on IPAL to be understood.

| Ethnography
The ethnographic study entailed overt, non-participant observation, over 13 days during a semester in Year 1 and 17 days during a semester in Year 2. The Year 1 semester had 13 to 22 h of classes per week (between 3 and 6 h per day), and the Year 2 semester had 13 to 18 h of classes per week (between 3 and 5 h per day).The observation days were determined partly by the timetabled activity and partly by logistical constraints of part time research.Observations were made in PBL, practicals, consultation skills and non-timetabled, informally organised, student meetings.Lectures were also attended with the students; however, no observations regarding IPAL were recorded in these.Early clinical experience teaching was observed in the teaching hospitals.The researcher went to the learning events with the students and access to the environments for the ethnography was by permission of the lead tutor.Notes were kept as open ended as possible to circumvent the risk of forming a prior impression of content.As the time in the field went on, areas started to emerge as themes.
Field notes were written during observation and transcribed electronically within a few days.Near contemporaneous transcription triggered memories of aspects that had been observed but not written down.Observations gave a close record of the overall process of sessions and included actual words and phrases the participants used.Situations not directly related to the learning process, such as side conversations during formal learning, were recorded.

| Semi-structured interviews
The student interview topic guide (Figure 1) included the following: what makes learning joined up, how do they learn and what do/do not they value.For staff (Figure 2), it included the following: how they saw integration, how students were working together and staff liaising, knowledge about course components and strengths/weaknesses of the curriculum.Interviews were audio recorded and transcribed verbatim but have been converted to plain English for ease of reading in this paper.

| Data Analysis
Thematic analysis of the ethnography and interview data was carried out using Quirkos v.1.5.2 (Quirkos Limited), a qualitative analysis package.Students are referred to by numbers P1-P24 and staff by P25-P40.
2][33] Hence, new themes were identified during the coding, for example, when specific elements of peer support were noted, such as help with pronunciation, which fitted better as a new separate theme from general peer support.
Two coding cycles were carried out by TM.In each case the, coding was double-checked by TM following completion of a cycle to ensure reliability.Additionally, SC and JH reviewed coding themes at key points, which were discussed in meetings.All coding was therefore ratified through discussion between TM, SC and JH following F I G U R E 1 Semi-structured interview schedules for Semesters 1 and 3. completion of a cycle, to ensure reliability.Emergent themes were reviewed and discussed in meetings between TM, SC and JH.The same coding strategy was used for both ethnographic and interview data.
The first cycle coding used process and descriptive coding, usually in combination, then sub-coding where appropriate.There was also simultaneous coding used in the first cycle. 34Descriptive coding was found to be most useful for the purposes of this research.This utilises a single word or phrase that summarises a chunk of data. 34Assigning descriptions therefore helped organise the data.The sub-coding approach helped to refine broader coding units.The use of 'process coding' with words ending with 'ing' called gerunds was an extension of the descriptive coding. 34This covered situations where participants were completing some sort of action such as 'Discussing'.'Simultaneous coding'-applying more than one code to a chunk of data 34 was necessary due to different ways of viewing the data.
The second cycle coding used an eclectic strategy with pattern coding and some influences of dramaturgical coding. 34This was deemed the most appropriate approach due to the multiple coding strategies in the first cycle.The second cycle principally utilised 'pattern coding' to identify patterns in the data and as such assembled bigger themes with little change in the first cycle coding.The ideals of 'dramaturgical coding' were also found to be useful.This type of coding represents chunks of data as a social play with the participants taking part in its performance.Dramaturgical coding was used to consider motives, obstacles and strategies adopted by the participants in managing the social situation of group interaction. 34Finally, the iterative process of writing the PhD thesis itself produced the themes as presented herein.

| Reflexivity
Ethnography relies on the accuracy and completeness of the observations and care must be taken to avoid observer/description bias.To mitigate this potential bias, the observations were approached with a naïve stance, never allowing assumption and restricted to purely recording what was observed even if more was known about a given situation than there was to be seen due to previous experience both as a student and as a teacher.

| RESULTS
The medical programme provided numerous opportunities for students to discuss topics they were learning.There were many occasions where one or more of the participants were observed to be giving IPAL to those less sure of the subject matter, thus becoming resources in each other's learning.Thus our data helps illuminate the mechanisms and processes through which IPAL takes place.
Giving IPAL to those less sure of the subject matter, thus becoming resources in each other's learning.Like any other learning environment, PBL does not equate with or guarantee IPAL.
The four themes identified in IPAL enactment were as follows: • Supporting each other in expressing and articulating concepts, defi-  b.Later P19 said to P16 about astigmatism 'so it's the degree your eye is not spherical'.P16 confirmed this (Field Notes, Physiology and Pharmacology Practical).Participating students were observed to build consensus by learning together in PBL discussions.Whilst PBL is designed to provide an environment where clinical scenarios can be discussed in light of new and existing learning, the effort students expended to help and support each other was an added benefit.Therefore, IPAL happens over and above the PBL process.One example is pronunciation.There was ready help when a participating student had difficulty, such as P12, pronouncing 'oogenesis'.A group consensus was reached as to the correct pronunciation.On another occasion, phonetic help was offered: P9 had trouble pronouncing thoracic.P12 corrected his pronunciation.P9 got it wrong again.P11 now corrected him/her and suggested 'try saying it with an s' (Field Notes, PBL).The value of input from other PBL group members was also discussed during interviews with P18, P22 and P24.These students talked about how they appreciated other PBL group members' contributions in their learning.Another asked peers for help, within/outside of their PBL group:

| Sharing resources
If you don't understand something I know there's several people that I could go to and they'll sit down and explain it to me and they won't call me stupid (Interview, P20).

| Help from students in the year above
Second year students were informal sources of support by being learning resources for first years.During Year 1, the group produced a poster, selecting smoking cessation as a topic.In a non-timetabled session where they were working on their poster, a presentation on a screen was used, obtained from a Year 2 student, as an example of what was required: I assumed the group had already made some slides and were discussing a plan.P2 pointed out to me that the slides had come from a student in the year above who had done a presentation on a different topic.They liked the pictures and found this useful.It was looked at by the group to see the sort of thing that was required and then they concentrated on their own plan (Field Notes, Non-Timetabled Session).
In interview, a Year 1 student, P2, talked about using second year students as a resource in understanding the required depth of learning.In physiology and pharmacology practical classes, students helped each other with tasks.For example, P16 figured out how to use an ophthalmoscope, and helped P18, who wanted to learn a particular exigency of the equipment.On another occasion, P22 clarified with P16 that he/she was doing near point measurement correctly.In an interview, P2 reported an example of peer teaching:

| Demonstration
Well last week I was in phys, physiology and pharmacology and I'd missed the session with the blood on the thumb so I just asked my friend okay will you do this with me and then he/she taught me how to do it and then we checked with the leader and they said it was right (Interview, P2).

| Situations where IPAL did not happen
Participating students did not always want to contribute, despite having relevant knowledge.P11 alluded to this following an anatomy session, commenting that they had done a lot of reading but did not want to get too involved.It is possible that P11 was concerned about being seen to know too much.Non-contribution to PBL discussions was a barrier to IPAL.P13 talked about how 'very clever people didn't want to contribute' and felt this could negatively impact on their learning by potentially missing out on knowledge.One staff member had explored this matter with students who felt they did not want to share material with peers after working hard on it themselves:  The PBL environment, with its group-driven ethos, was the main arena in which IPAL could be seen to be enacted by the study participants, above and beyond discussion of a clinical case.However, it could be generalised that discussions in PBL sessions were composed entirely of formal help and support, as befits the ethos of PBL. 29 Students' participation in groups, in line with the communities of practice theory, 27,28 puts in place a scaffold that allows IPAL to be enacted.
The present research has recorded numerous occasions where IPAL occurred, including assistance from the wider medical school community of practice.A study of communities of practice similarly identified the value of information from peers given informally within group learning.Although in this study learning was seen as something one did by oneself, PBL groups were acknowledged as a forum for correcting peers when they were wrong about a certain subject.Peers would help each other in the PBL environment, sharing resources, and over the course of the year, peers and PBL overtook lectures and books as learning resources. 29is study also shows how IPAL can be continuous, across different learning spaces, timetabled and non-timetabled.The findings indicate that it may be important to provide informal/untimetabled spaces for IPAL to emerge.3][24] Similarly, IPAL can occur within assigned groups. 26As clinical students became more experienced, specific peer support such as feedback on performance in a clinical encounter has been noted. 25 the present study, IPAL became part of integrated learning, 30 with group members themselves becoming a learning resource.
Receiving help and support from peers became intertwined with the integrated learning experience.Participating students began to expect integrated learning, including opportunities to learn informally with and from their peers, and indeed to resent situations where it wasn't seen to be happening.The dynamic between peers contributed to the success of the learning process and to building togetherness within the group.It is possible that natural competition in medical study may make what look like helpful statements condescending.However, the fact that peers sought support from each other, and resented situations where this support was not forthcoming, is evidence that the students valued IPAL.There were obstacles to the enactment of IPAL.When the group dynamic broke down, there was a risk of compromise to the group's cohesion, and the integrity of the learning process was threatened.
6][37] One study reported deleterious effects of competition on medical students' learning in an institution that did not grade the students except to privately tell them their quartile once a year. 38Perhaps academic grading of medical students would benefit from review, and the aforementioned approach 38 could help promote a collaborative learning environment conducive to informal peer support.
Evidence from the interviews suggests that help and support from peers was valued, with reliance on peers for learning and enrichment of the learning process.An American study of medical students' use of Twitter similarly found a dependence on peers and noted the value of building a community through informal learning and sharing of resources. 39Not helping peers risked compromising learning, pointing to an expectation that students would help each other.This shows the value of setting up learning processes in such a way that IPAL can be consistently and systematically facilitated.

| Strengths and Limitations
The in-depth nature of the observations enabled documentation of students' behaviours and perceptions across a variety of learning environments.Some events and details may have been missed whilst writing during observation; however overall, the method allowed a non-directive impression to be formed, through note-taking about peer interactions and recording details of instances of IPAL.

| Recommendations
Further research could evaluate the effect of integration on IPAL via video ethnography of multiple groups.An observation schedule derived from this study's findings-similar to the Roter and Larson 40 schedule for observation of health care communication-could be employed to capture further dimensions and levels of detail.
The role of the tutor in facilitating peer support could illuminate processes of informal learning.This could be achieved via a focus group study with tutors of varying levels of experience and a questionnaire to explore students' perceptions of the tutor role.
Research investigating whether IPAL can coexist with a competitive culture could be conducted using a scale such as that of Ryckman and Hammer. 41This scale measures the influence of personal development and competition, studying the characteristics of people who want to do well, without a negative impact on others, and how people use competition to better themselves.The scale could be used to explore how IPAL and competition can be recognised and accommodated to work together in complement.

| CONCLUSION
IPAL developed as part of integrated medical education at a UK medical school.IPAL took the form of support with the learning process within and outside the PBL group, extending to the wider peer group of medical students in a year and sometimes the year above.Where situations arose that obstructed informal support, there was risk of compromise to the learning process.IPAL has the potential to provide beneficial learning support to students in any learning environment where group discussion/collaboration occurs in a community of practice 27,28 and has implications in driving forward improvement in health care education internationally.Ultimately, we found that IPAL was valued and expected by students.
We have demonstrated how the mechanisms and processes of IPAL are enacted at this particular medical school, helping to fill this gap in the literature.
PBL, in ethos and approach, can provide a learning environment conducive to IPAL, given that PBL is about sharing and evolving and discussing together as with non-directive facilitation by a tutor.Within the formal structure of PBL, informal learning amongst peers was observed.Whether or not such IPAL takes place was shown to be dependent on other factors, such as competitiveness, reticence or shyness.IPAL does not necessarily thrive in PBL, depending on the tutor's style (active tutor or group facilitator), groupF I G U E 2 Staff interview schedule.Points 1, 2, 3, 9, 10, 11 and 13 were the questions on the original interview schedule.The other points were added following reflection during the fieldwork.dynamics or the pressure of exam performance.Therefore, like any other learning environment, PBL does not equate with or guarantee IPAL.

•
Situations where peer support did not happen3.1 | Supporting each other in expressing and articulating concepts, definitions and termsParticipating students helped each other in environments outside timetabled commitments.IPAL took place in various side rooms, in the university library or medical school.Support could take the form of a definition, such as when P3 was observed to ask those present what CBT was, and P4 responded 'cognitive behavioural therapy', in a non-timetabled study group to discuss a poster they were creating.Here, the participating students were also observed helping each other with anatomy learning.P4, P5 and P7 were working together on the structure of the pelvis, and in the formal anatomy session which followed, this co-operation continued: P4 explained which was anterior and posterior on the pelvis and P4 and P5 discussed where ligaments attached.All four of P7, P5, P11 and P4 worked together to identify structures (Field Notes, Anatomy).IPAL outside the timetable thus promoted and fostered support in timetabled sessions.On another occasion, one student was unsure about the bones of the skull, and peers came to their assistance:They were all looking at the bones of the skull and P22 asked the others about a skull bone and the region at the top of the skull, both of which P16 and P18 helped P22 out with (Field Notes, Non-Timetabled Session).
IPAL outside the timetable thus promoted and fostered support in timetabled sessions.Students also supported each other in learning medical terminology during practicals: for example, when one student wanted to know what astigmatism was (a).Later in that session, there was a follow up question, when the participant wanted to confirm their new understanding (b): a. P19 said 'what's astigmatism'.P16 said 'it's when your eye is like rugby ball shaped'.
At times during PBL, students would share resources.Following a discussion about cerebral oedema and hydrocephalus in PBL, P18 offered to put a relevant paper on the group's page online.Another instance in PBL was where P21 talked about a point of interest, after looking at a resource provided by another student: P21 talked about an 'interesting theory' about hydrogen peroxide, free radicals and damage to the substantia nigra.P21 had referred to P18 posting this on the group's Facebook page and P18 said, 'you're welcome'(Field Notes, PBL).These examples show how students go above and beyond what is expected of them in PBL sessions, in supporting each other's learning.

3. 3 |
Help from students in the same year group Learning in PBL groups can foster IPAL in the wider medical school.P2 talked about the value of PBL in creating a community of students, helping each other, forming friendships, getting to know different groups, working with others rather than individually and working in teams.Another student commented on the benefit of working with students outside the PBL group: I mean obviously yeh in formulating your learning outcomes that you've got to study for the week you do that with your PBL group but I think it's more about friends from the course I think that's cause I find it really beneficial to work with someone else (Interview, P1).P1 talked about how learning with peers from another PBL group enabled diverse learning objectives and perspectives.P24 talked about the role of friends in explaining uncertain subject areas.P20 reported going to the anatomy room twice weekly with a friend: We'd go once to like just quickly go over everything and then we'd go again and we'd test each other (Interview, P20).
Sometimes, peers assisted each other via physical demonstration in further evidence of the mechanisms and processes of how IPAL is enacted.In anatomy, P4 and P5 were observed working together on the orientation of the radius bone.P4 said 'supination is carrying soup' and demonstrated this aide memoire through gesture.The students attended laboratory practicals as part of their timetabled learning.During a microbiology practical, students requested help which others readily gave, as observed in the field notes: P9 and P1 asked P11 [who was sitting opposite them] 'how you do the blotting thing?' P11 said, 'you touch it really gently' (Field Notes, Microbiology Practical).

I
have spoken to students who feel that they're doing all this work why should they share it with, with others if they've spent 35 hours in the library reading and understanding material, why should they then give that material to other people, surely it's the amount of work you put in is the amount of work you get out, but hopefully they can see by the end of the process that actually it does help by explaining to other people what you've learnt actually and working with others and working through things as a team actually improves the outcome (Interview, P38).Staff member P38 remarked that some students were competitive, presenting a barrier to sharing information and working with peers.Staff member P31 similarly felt that students viewed themselves as in competition with each other.P6 confirmed this: Unfortunately medicine has a very competitive culture so I think that's kinda [sic] inhibiting the educational development of peers of each other because unfortunately a lot of people are viewing there's there is a competitive culture so it's kinda [sic] people are acting as rivals and then by other people knowing stuff rather than having a developmental effect on others it's having more of perhaps an intimidating or feelings of aghh I don't know as much as them (Interview, P6).In interview, P4 expressed a preference to work on their own, inhibiting IPAL: Like how they help me I don't know because I think I kind of like to do stuff myself so like even if it was like a group work I'd still kind of do everything myself (Interview, P4).

4 |
DISCUSSIONThis paper highlights a variety of ways in which IPAL was enacted, thus illuminating our understanding of what IPAL looks like in practice.IPAL happened widely across learning situations ranging from explanation/clarification, sharing resources, guiding pronunciation, to physical demonstration of skills.Whilst important to students, IPAL was not always available due to unwillingness or perceived lack of knowledge.