Our results indicate that student experience with near-peer PBL tutors was better for most domains of student experience with their PBL tutor compared to both single and multiple staff PBL tutors.
The theoretical basis for the success of peer-assisted learning may rest on two main premises: the concepts of cognitive congruence and social congruence . Cognitive congruence relates to the peer teachers’ sharing or being able to relate to the knowledge base and requirements of the students, thus enabling them to express themselves using the students’ language, thereby making it easier for students to grasp difficult concepts. Social congruence refers to peer teachers’ ability create a positive learning environment where students feel safe to show ignorance and make mistakes, through communicating empathetically and informally with students and showing interest in them [2, 9, 10].
It has been argued that through their recent experience with the course, near-peer PBL tutors have a sensitivity to the needs of students . They display more socially and cognitively congruent behaviour such as better understanding of student difficulties and their practical needs regarding assessments, creating a more relaxed atmosphere within the group and being more interested in the students’ experiences [4, 11]. As Year 3 and 4 students on the MB BS, the near-peer tutors in this study are acutely aware of the PBL process from the student learning perspective and what is required of students in Year 2, having recently experienced it themselves. This ‘insider’ knowledge may give them more legitimacy in the PBL facilitation process in the eyes of the students. Near-peer PBL tutors being perceived as appearing interested, providing appropriate guidance, intervening when the group was experiencing problems, encouraging sufficient group discussion, and providing helpful verbal feedback to a higher degree than both groups of staff PBL tutors, and providing helpful written feedback to a higher degree than multiple staff PBL tutors may be explained by the more congruent behaviour on the part of the near-peer PBL tutors in these areas.
Another possible explanation for these findings is that peer tutors may put greater effort into, and spend more time on, preparing for the PBL tutorial. It takes considerable time to review each week’s PBL case, accompanying learning material and the documents prepared by students about the learning objectives they have identified, and also to provide feedback to students about their performance; staff may not have the time they would ideally like to dedicate to this around their other teaching, research and clinical commitments. Additionally, the topics are directly relevant to the near-peer tutor’s own learning needs and so they may view time spent with the PBL material as a valuable period of revision for their next year of study and future assessments. We do not, however, have any data relating to preparation times of PBL tutors to substantiate this explanation. It is also not clear from this study whether peer tutors are displaying other behaviours which may lead to increased student satisfaction, such as helping students with exam preparation, advice, and study tips although responses to the open-ended question regarding PBL tutor performance suggest that this is happening in addition to facilitation of the PBL session.
Ratings for the newly qualified doctor tutors sit between the higher rated near-peer tutors and the single staff tutors. Newly qualified doctors as tutors represent an example of ‘cross-level’ peer teaching, that of recently graduated doctors teaching medical students . Researchers have found that the quality of teaching sessions and perceived learning from such sessions is the same for near-peer and cross-level teachers [12, 13]. However, characteristics such as enjoyment of the sessions, relevance of teaching to the students’ needs, and delivery of teaching have been found to favour near-peers in contrast to peers at a further distance; this has been attributed to reduced congruence between junior doctors and medical students [12, 13]. As such, it is possible that our findings are attributable to the newly qualified doctor tutors having less congruence than the near-peer tutors, but more congruence than the staff tutors.
Near-peer, newly qualified doctor and single staff PBL tutors were rated more highly than multiple-staff PBL tutors. The reasons for this are unclear. Whilst it could be argued that this finding reflects students’ valuing a continuity of the tutor relationship over the course of the academic year, all of the newly qualified doctor tutor groups also had multiple tutors in the year. This makes explanations based on the amount of time tutors spend with the student during the year, or the number of tutors facilitating each group less plausible. It is possible that staff tutors who share a group are less committed to the PBL process for some reason. Alternatively, it may be that a closer social and cognitive congruence exhibited by the newly qualified doctor tutors (compared to the staff tutors) counters some issues related to having multiple tutors.
There were no statistically significant differences between the four groups relating to the PBL group performance questions, suggesting that these characteristics of the PBL experience are somewhat independent of the tutor characteristics evaluated in this study. It is notable that for all tutor types, the group experience questions resulted in lower scores than the tutor questions. Thus, all tutor types need to help their students develop in these areas.
Limitations and Future Research
Whilst student perceptions of their learning environment are important, the evaluation data used in this study are subjective and may not accurately reflect objective measures of tutor performance or adherence to PBL principles during their sessions. All PBL tutors at NMS are required to undergo a PBL training day to encourage uniformity of PBL facilitation methods across tutors, and tutors are additionally required to have one peer observation of their PBL tutoring every academic year. There are, however, currently no objective measurements made of tutor performance during PBL at NMS. In the future, it would be worthwhile undertaking research to identify the specific behaviours of highly rated PBL tutors in each of the four groups of tutors through observation, and seeing how these behaviours match to expected facilitation methods and other effective tutor attributes.
There is inevitably some variation between tutors within each of our four groups. Therefore, although near-peer PBL tutors as a group are rated highest by students, variation amongst each tutor-type group means that not all individual near-peer tutors compare more favourably to all individual staff tutors. An observational study of near-peer and faculty tutoring in PBL groups revealed significant variations in tutor practices within groups of near-peer and faculty tutors; this within-group variation was greater than the variation across the tutor types . Thus, it would be important to take account of individual differences in facilitation skills if planning to introduce near-peer PBL tutors and ensure that training meets the needs of all prospective tutors.
Finally, student satisfaction with their PBL tutor may not equate with improved learning. We have not linked these findings to performance in any of our assessments, or actual clinical performance (as exams are inevitably a surrogate for that performance). Generally, students in peer-tutored PBL groups have achieved similar outcomes in assessments [3,4,5], but the picture is not clear  and more research is needed in this area to ensure that peer tutoring in PBL results in at least equivalent outcomes to the faculty tutoring it would be replacing.
Additional important future research would include investigating near-peer PBL tutors’ experiences of PBL as a tutor. Such research could elucidate the benefits for tutor’s continuing undergraduate training when they return to their course and generalizable skills for future practice as a doctor. It could also identify any areas where they struggled, for example shifting their role from student to tutor on their own course of study or developing facilitating skills without slipping into teaching. Such information would help to develop training for future near-peer tutors.