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RESEARCH ARTICLE
Peer-assisted learning: time for nomenclature
clarification
Alexander Olaussen
1,2,3
*, Priya Reddy
1
, Susan Irvine
1
and Brett Williams
1
1
Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne,
Australia;
2
Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia;
3
National Trauma
Research Institute, The Alfred Hospital, Melbourne, Australia
Background: Peer-assisted learning (PAL) is used throughout all levels of healthcare education. Lack of
formalised agreement on different PAL programmes may confuse the literature. Given the increasing interest
in PAL as an education philosophy, the terms need clarification. The aim of this review is to 1) describe
different PAL programmes, 2) clarify the terminology surrounding PAL, and 3) propose a simple pragmatic
way of defining PAL programmes based on their design.
Methods: A review of current PAL programmes within the healthcare setting was conducted. Each
programme was scrutinised based on two aspects: the relationship between student and teacher, and the
student to teacher ratio. The studies were then shown to fit exclusively into the novel proposed classification.
Results: The 34 programmes found, demonstrate a wide variety in terms used. We established six terms, which
exclusively applied to the programmes. The relationship between student and teacher was categorised as
peer-to-peer or near-peer. The student to teacher ratio suited three groupings, named intuitively ‘Mentoring’
(1:1 or 1:2), ‘Tutoring’ (1:310), and ‘Didactic’ (1:10). From this, six novel terms all under the heading of
PAL are suggested: ‘Peer Mentoring’, ‘Peer Tutoring’, ‘Peer Didactic’, ‘Near-Peer Mentoring’, ‘Near-Peer
Tutoring’, and ‘Near-Peer Didactic’.
Conclusions: We suggest herein a simple pragmatic terminology to overcome ambiguous terminology.
Academically, clear terms will allow effective and efficient research, ensuring furthering of the educational
philosophy.
Keywords: PAL ;peer-assisted learning;near-peer;mentor;tutoring;didactic;near-peer teacher
*Correspondence to: Alexander Olaussen, Department of Community Emergency Health & Paramedic
Practice, Monash University Peninsula Campus, PO Box 527, McMahons Road, Frankston, Victoria 3199,
Australia, Email: alexander.olaussen@monash.edu
Received: 12 January 2016; Revised: 17 June 2016; Accepted: 19 June 2016; Published: 12 July 2016
Peer-assisted learning (PAL) as an educational
method has been around since Socrates and Plato
began questioning one another’s ideas in small
groups (1). In recent times, PAL has gained increasing
attention across many different healthcare disciplines
and educational sectors (1). Naturally following such is
a growing body of evidence to determine its usefulness.
The benefits of PAL has been well-described by Topping
et al. (1) and clearly pertain to all stakeholders (i.e., the
universities, the peer-teacher, and the peer-learner) (13).
There appears to be a climate of readiness to formally
incorporate PAL into different areas of healthcare studies.
PAL has one philosophy: students learning from stu-
dents (4). Two different relationships between the students
and some variations in the arrangement of PAL pro-
grammes have carved out the different methods described
to date. Given the simple and common root that all PAL
programmes stem from, the extensively varying terminol-
ogies used is peculiar. Several mismatched terms exist
throughout the literature. Examples of these include, but
are not limited to: peer-led teaching, peer-led training, peer-
tutoring, peer-teaching, collaborative learning, collaborative
tutoring, cooperative learning, supplementary instruction,
tutor-less group, peer supported learning, shared learning,
co-teaching, co-tutoring, student partnership, facilitated
peer mentoring, and similar variations of near-peer or
cross year. The most commonly used term peer-assisted
learning is arguably just an umbrella term encompassing
all PAL programmes, and as such this term is non-
descriptive (1).
PAL has been extensively researched in the pedagogy
(5) and seems to carry less confusion about the terminol-
ogy than in andragogy. This may be because adult
learners are more heterogeneous than the young, as well
Medical Education Online
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Medical Education Online 2016. #2016 Alexander Olaussen et al. This is an Open Access article distributed under the terms of the Creative Commons
Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or
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1
Citation: Med Educ Online 2016, 21: 30974 - http://dx.doi.org/10.3402/meo.v21.30974
(page number not for citation purpose)
as the environment in which they learn differs. The
variance also appears in the preferred learning methods
and the personal motivation (6). Adult learners’ ‘richest
resources for learning reside in the adult learners
themselves’ (6) (p. 45). Focus on experience-based tech-
niques, including PAL, is therefore beneficial.
Terms need to be consistent for a number of reasons.
Firstly, programme implementation is facilitated chiefly by
clear terminology, communication, and intent. Secondly, for
research purposes building an evidence-based foundation is
more achievable. The uncertainty and incongruence around
the terms weakens and confuses the research starting point.
Thirdly, communication across institutions and disciplines is
eased through accurate and consistent terms.
Attempts to clarify the terminology exist. Ladyshewsky (7)
outlined different PAL methods and suggested groupings
based on common ‘indices’. Ten Cate and Durning (8)
designed a framework distinguishing between three elements.
Ladyshewsky (7) argues there are two common indices
that can describe all methods of implementing PAL
namely, 1) equality (e.g., to which extent learners take
direction from each other) and 2) mutuality (e.g., in
relation to the learners’ discourse). Although this may be
theoretically sound, its applicability is limited by the non-
practical definitions. Moreover, a single PAL programme
may be difficult to define within the suggested category,
as the indices are not quantifiable as well as overlapping.
Ten Cate and Durning (8) on the other hand distinguish
PAL programmes based on three believed core compo-
nents: 1) education distance, 2) group size, and 3) formality.
The distance is undoubtedly a key factor to consider
and should differentiate between peers and near-peers.
Further, the size of the group is also important as it has
practical implications for the educational providers and
correlates with students’ preferences and learning (9).
There is limited evidence around the impact formality
has on the PAL outcomes. Furthermore, this is difficult
to include in nomenclature given the spectrum formal
involvement lies on and its vast variation amongst dif-
ferent education institutions.
Despite these clarifying attempts, inconsistencies con-
tinue to exist throughout the literature. This may be be-
cause the suggested components are difficult to define. We
therefore aim to 1) describe the different methods in which
PAL programmes have been incorporated to date, 2) clarify
the terminology surrounding PAL, and 3) propose a
simple pragmatic way of defining PAL programmes.
Methods
We searched five databases (PubMed, Cinahl, Medline,
Proquest, and Embase) and two grey literature websites
(www.greylit.org and www.tripdatabase.com), in a scop-
ing review manner for articles of relevance (10). The
articles were narrowed down based on the key concepts of
describing the implementation of a PAL programme and
pertaining to the healthcare education. We included
studies describing different forms of PAL in order to
i) show the wide and varied approach PAL can take, and
ii) to ensure that our suggested novel terms would be
applicable to all methods of PAL practice.
We derived the new terms from a consensus process
stemming from the different PAL methodologies within
the literature. In accordance with previous nomenclature
clarification attempts within other fields, we desired to
keep well-established acronyms where possible, whilst
also clarifying any confusion through making the novel
terms more accurate in their description (11).
Results
We describe 34 different approaches to PAL. From the
findings, a clear disparity in nomenclature was deter-
mined, further highlighting the importance of formalising
the terminology around PAL. The 34 programmes
reviewed are listed in Table 1. Their methods and used
terminology are tabulated.
Given the wide variety, we propose a new pragmatic
indexing approach, which is based on unambiguous
components. Based on components commonly used to
describe the programmes, we propose the new classifica-
tion relates to the relationship between the students and
the ratio of students to student-facilitators (Fig. 1).
Discussion
The umbrella term: PAL
PAL is the umbrella term and encompasses all pro-
grammes in which students learn from students, and does
not specifyany more than that. There seems to be confusion
in the literature between PAL as an umbrella term and
peer-to-peer learning. Peer-to-peer is the appropriate
name when the students are peers; as opposed to near-
peers. Considering that both students (i.e., the teacher and
the one being taught) are learning and benefitting (3, 4)
may alleviate the confusion. Thus, the term peer-learner
should not solely describe the student which it often does
but rather describe both the teacher and student. We do
not wish to alter this terminology because the acronym
PAL is widely known and utilised.
Relationship between students: peer or near-peer
We consider peer and near-peer the first key separation
because cognitive congruence is a vital component of
learning (8).
Our proposed classification therefore immediately begs
the question what is a peer? Is a peer merely someone at
the same academic year level, or is it more appropriate to
distinguish based on ability? Whilst disagreement on this
question flourishes in the literature, Ladyshewsky (7) and
King (46) concludes that without pairing students’ status
and ability, the programme becomes simply tutoring, not
Alexander Olaussen et al.
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Tabl e 1. An overview of different PAL programs, their method and used terminology, presented sequentially based on the novel
terminology
Proposed
terminology and
the corresponding
teacher-to-student
ratio Study title (reference) Method
Suggested name
by the study
Peer-to-peer
Peer Mentoring
(1 to 12)
Relationship between retention and peer
tutoring for at-risk students (12)
26 ‘at-risk’ nursing students were randomised
to a PAL or control group. 20 were given peer
tutors (who had a higher academic score than
the learner) in a one to one fashion.
‘Peer tutoring’
Clay modelling for pelvic anatomy review for
third-year medical and physician assistant
students (13)
23 third year medical students taught one
another female anatomy after listening to a
lecture and seeing a demonstration.
‘Peer learning (peer
learner and peer
teachers)’
Learning in the simulated setting: a comparison
of expert-, peer-, and computer-assisted
learning (14)
60 medical students were randomised to three
groups. All were given a brief lecture. The peer
group was split into groups of two where they
taught each other while the other group
consisted of computer-assisted learning.
‘PAL’
Peer assisted learning in surgical skills
laboratory training: a pilot study (15)
Residents taught each other with and
without guidelines then provided feedback
to each other on the skills practiced.
‘Peer feedback’ and
‘peer teaching’ was
referred to as PAL
Peer Tutoring
(1 to 310)
A controlled trial of peer-teaching in practical
gross anatomy (16)
160 second year medical students, 80 of
which were controls. Half the group would
dissect then they would teach the next
group then retire to study while the second
group dissected. The second group then
showed the first group.
‘Peer teaching’
A comparisonof learning outcomes and attitudes
in student- versus faculty-led problem-based
learning: an experimental study (17)
Second year medical students were
assigned a peer within groups of 10 to
facilitate tutorials.
‘Peer facilitator’
Student-led tutorials in problem-based
learning: educational outcomes and students’
perceptions (18)
Third year medical students taught
each other in groups of 810.
‘Student led tutorials’
Involvement in teaching improves learning in
medical students: a randomized cross-over
study (19)
135 first year medical students rotated the
role of tutor and tutee in small groups with
two tutors per group.
‘Peer educators’
Knowledge transfer of spinal manipulation skills
by student-teachers: a randomised controlled
trial (20)
292 third and fourth year medical students
were taught in groups of 612 by fellow
peers (who received brief teaching course).
‘Student teachers’
Peer teaching: a randomised controlled trial
using student-teachers to teach
musculoskeletal ultrasound (21)
151 students, 75 of which were taught by
nine student teachers of the same year.
‘Student teachers’
Peer Didactic
(1 to 10)
Peer assisted versus expert assisted learning:
a comparison of effectiveness in terms of
academic scores (22)
70 fourth year medical students where one
group (35 students) was given a lecture by a
peer who had the highest academic score.
‘Reciprocal peer
teaching’
Near-Peer
Near-Peer
Mentoring
(1 to 12)
Reducing student anxiety by using clinical peer
mentoring with beginning nursing students (23)
30 ‘freshmen’ nursing students were paired
with individual ‘sophomore’-level medical-
surgical peer mentors.
‘Peer mentoring’
Peer-assisted learning
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Tab le 1 (Continued )
Proposed
terminology and
the corresponding
teacher-to-student
ratio Study title (reference) Method
Suggested name
by the study
Near-Peer
Tutoring
(1 to 310)
Can near-peer medical students effectively
teach a new curriculum in physical
examination? (24)
83 third year medical students were taught
in groups by nine 4th/5th years.
‘Near peer teaching’
Peer assisted learning in patient-centred
interviewing: the impact on student tutors (25)
Two third year medical students taught
groups of six first year medical students.
‘Student tutors’
Student teachers can be as good as associate
professors in teaching clinical skills (26)
Medical students in year two and above taught
first year medical students in groups of 56.
‘Student teachers’
Formal peer-teaching in medical school
improves academic performance: the MUSC
supplemental instructor program (27)
Medical students from upper levels taught
junior students in groups of 46.
‘Supplemental
instructors’
Peer tutoring and student outcomes in a
problem-based course (28)
Medical students who had completed a
particular course two semesters prior
taught current students in groups of 48.
‘Peer tutors’
Advanced Cardiac Resuscitation Evaluation
(ACRE): a randomised single-blind controlled
trial of peer-led vs. expert-led advanced
resuscitation training (29)
One sixth year medical student taught
cardiac resuscitation to nine fifth year
medical student.
‘Peer instructors’ &
‘Peer led training’
Are fourth-year medical students effective
teachers of the physical examination to first-
year medical students? (30)
Nine fourth year medical students taught
first year medical students in groups of four.
‘Student preceptor’
Peer-assisted learning from three perspectives:
student, tutor and co-ordinator (2)
Small group sessions with 12 students per
two peer tutors. Peer tutors were generally
one year senior. Consultants reviewed the
teaching and learning material. Peer tutors
received training in the relevant skills.
‘Peer tutors’ within a
PAL framework
Impact of peer teaching on nursing students:
perceptions of learning environment,
self-efficacy and knowledge (31)
179 first year nursing students were taught
by 51 third year students.
‘Peer teaching’
Peer-assisted learning in the acquisition of
clinical skills: a supplementary approach to
musculoskeletal system training (32)
Four fourth year medical students trained
28 second year students with 218 control
students.
They called it ‘PAL’
but referred to the
near peers as
‘student trainers’
Undergraduate rheumatology: can peer-assisted
learning by medical students deliver equivalent
training to that provided by specialist staff? (33)
12 senior medical students trained 45
second
‘Student trainers for
PAL’ year students.
Randomized surgical training for medical
students: resident versus peer-led teaching (34)
60 third year medical students taught by
fourth years in groups of 45.
‘PAL’
Peer-led resuscitation training for healthcare
students: a randomised controlled study (35)
122 first year medical, dental, nursing and
physiotherapy students taught by second
years in groups of 1012 with two peers (of
1 year higher) per group.
‘Student instructors’
in ‘peer led’ training
Near-peer teaching in anatomy: an approach
for deeper learning (36)
12 fourth year medical students ran
dissection classes for first and second year
students (no specific number was stated
but it is noted that the entire first and
‘Near peer teachers’
abbreviation used
‘NP’ Students were
called ‘tutees’
Alexander Olaussen et al.
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peer-tutoring. The role of the faculty will be in facilitating
and monitoring the relationship between their students.
The definition of a near-peer is generally clearer, and
consists of two participants that are at least one academic
year apart. However, exceptions exist. For instance, when
PAL is used within interdisciplinary programmes, (47)
students may have different abilities although being at the
same academic year level. We suggest that cases of inter-
disciplinary PAL programmes should be referred to as near-
peers when they are at the same acedemic year level.
Ratio of students: mentoring, tutoring, or didactic
In concordance with Ten Cate and Durning (8), we also
consider the number of students in the group crucial. This
correlates with students’ preferences (9), therebyaffecting the
likelihood of engagement and implicitly learning. Ten Cate
and Durning (8) split the size of the PAL group into only two
groups (i.e., 1 to B3 students, and 1 to ]3 students). Given
the varying dynamic of different group size, this distinction
may be too blunt. We therefore propose a three-way split
which is more consistent with traditional academic structur-
ing, namely mentoring, tutoring, and didactic.
We define a programme as a mentor programme if the
teacher to student’s ratio is 1:1 or 1:2 (i.e., a microenviron-
ment). Mentoring involves positive role modelling and
reinforcement, supplemented by counselling, often used
for disadvantaged groups (3). PAL by mentoring is bene-
ficial in that it provides a more intimate setting where
students are more inclined to ask questions and express
Tab le 1 (Continued )
Proposed
terminology and
the corresponding
teacher-to-student
ratio Study title (reference) Method
Suggested name
by the study
second year class was involved in this
programme). 23 ‘near-peer teachers’ were
assigned to each small group.
Peer-assisted versus faculty staff-led skills
laboratory training: a randomised controlled
trial (37)
89 third year medical students divided into
three grou ps of controls (28), PAL (run b y fourth
and fifth years) (29), and staff taught (26).
‘Cross year’ PAL
Near-Peer
Didactic
(1 to 10)
A vertical study programme for medical
students: peer-assisted learning in practice (38)
Fifth year medical students provided five sets
of 2 h case based lectures in groups of 1015
medical students from years one to four.
‘PAL facilitators’
Effects of peer-assisted training during the
neurology clerkship: a randomized controlled
study (39)
Six medical students who had completed a
neurological clerkship the semester prior
taught 66 medical students currently
undertaking their clerkship.
‘Peer tutoring’
A multi-level assessment of a program to teach
medical students to teach (40)
28 fourth year medical students taught 117
second year medical students.
‘Student teachers’
The role of students as teachers: four years’
experience of a large-scale, peer-led
programme (41)
Eight medical students within their clinical
phase taught 358 junior medical students in
their pre-clinical phase.
‘Peer led teaching’
and the learners were
referred to as ‘tutees’
Peer-assisted learning: a novel approach to
clinical skills learning for medical students (42)
Three year 45 students taught 86 year 1 2
students: one near-peer to 23 students, 1 to
29 students, and 1 to 34 students.
‘Trainer and Trainee’
Clinical skills education: outcomes of
relationships between junior medical students,
senior peers and simulated patients (43)
125 second year medical students were
trained by 11 sixth year students.
‘Cross year PAL’
A three-day anatomy revision course taught by
senior peers effectively prepares junior
students for their national anatomy exam (44)
105 second year medical students taught
by four fourth year students in a lecture
setting.
‘Course tutors’
Peer-assisted teaching: an interventional study
(45)
One third year paramedic student taught 12
first year paramedic students with the
presence of a paid sessional staff member.
‘Peer teaching’
Peer-assisted learning
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uncertainties. Furthermore, the likelihood of student in-
volvement in the process and direct monitoring of student
progress by the teacher can be easily facilitated. The obvious
drawback of PAL mentoring lies in resource demand.
Finding compatible pairs is a challenge for the institution.
We define a tutorial as a setting where there is one
teacher to between 3 and 10 students. Tutoring is often
highly focused on curricula content and is characterised by
the assignment of specific roles (i.e., tutor and tutee), most
often with clear guidance around the structure (3). The
benefits of peer-tutoring are i) less resource demanding, ii)
increased possibility for the university to follow up their
peer-teachers, and iii) raised and diversified collaboration
given the larger group and the inherent broader range of
views and perceptions. However, this also leads to the
possible drawback that quiet students may remain quiet
and unnoticed, thereby limiting the utility of such a PAL
programme for those students.
We define a programme as didactic if the teacher to
student’s ratio is in excess of 1:10. Among the vast array
of learning methods and styles, although less common in
PAL, is a class delivered lecture format. This one
directional method is beneficial in that it uses minimal
resources and teaches the peer-teacher to both prepare
and present in front of a large group. However, limited
possibilities for feedback, participation, and student
interaction are considerable drawbacks to this method.
Based on the above-described components, every PAL
programme will fall, mutually exclusively, under any of six
categories. Figure 1 outlines these categories and illustrate
their corresponding suggested names.
Conclusion
We have herein tabulated the main variations in PAL
programmes and proposed a novel nomenclature classifi-
cation. We are not classifying previous authors and their
terminology as wrong, nor do we wish to correct them. We
merely encourage future research in this field to be more
consistent with its terminology. This will better enable the
formal integration of PAL into educational programmes.
To overcome the shortcomings of previous attempts
at clarifying the terminology, we have proposed a clear,
intuitive, and unambiguous nomenclature in which pro-
grammes mutually exclusively belong to just one term.
To broaden the platform of research around PAL and to
allow easy integration across institutions, consistent terms
and definitions are necessary. We urge consistent use of the
PAL terms based on the suggested groupings offered in
this paper. Expansion of the MeSH (Medical Subject
Headings) terms is necessary. It may be anticipated that
new terminology introduction may be inconvenient at
first, and it is unlikely that a consensus will be reached
quickly; however, we believe the long-term benefits uni-
form terminology has on research and education outweigh
this hindrance.
Conflicts of interest and funding
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the
paper.
Disclaimers
The views expressed in this article are those of the authors.
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