Becoming a physiotherapist - a qualitative study exploring students’ perspectives on peer assisted learning in physiotherapy education

ABSTRACT

Background

Peer assisted learning (PAL) has become increasingly popular in higher education, and a range of benefits have been reported for students. However, there is scant knowledge on PAL study groups in physiotherapy undergraduate training.

Objectives

This study aimed to generate in-depth knowledge about the experiences of PAL study groups from the perspective of physiotherapy students.

Methods

We conducted focus group interviews with 15 first-semester students who had attended PAL study groups, and 8 third-semester students who had been PAL leaders. The interviews were analyzed using an inductive, thematic analysis.

Results

Four main themes were generated: 1) An overwhelming transition – Eased by PAL study groups; 2) The significant role model – Creating safe learning environments; 3) Building a bridge between theory and practice through scaffolding; and 4) Time to mature and filtered knowledge.

Conclusion

Overall, we found that PAL study groups formed an important community of practice, and that the PAL leaders became important role models, providing academic, social, and emotional support. Students learning from students in PAL study groups seemed beneficial to bridge theory and practice. Our findings support the implementation of PAL study groups as a supplement to formal teaching and suggest that PAL aids students’ transition to the university environment.

KEYWORDS:

• Peer assisted learning
• peer assisted learning study groups
• undergraduate physiotherapy training
• physiotherapy

Background

Peer assisted learning (PAL) has become increasingly popular in higher education. This is driven partly by increased student enrollment, limited teaching resources, and a push for cost efficiency (Boud, 2001; Guraya and Abdalla, 2020; Stigmar, 2016). Although PAL has been defined as “the acquisition of knowledge and skill through active help and support among status equals and matched companions” (Topping, 2005) it is considered an umbrella term, encompassing a variety of learning methods and activities (Boud, 2001; Olaussen, Reddy, Irvine, and Williams, 2016; Ross and Cameron, 2007; Topping, 2005). One explicit form of PAL is voluntary, peer-led study groups, originated as supplemental instruction (SI) in the United States in the 1970s (Arendale, 1994). Similar variants, termed PAL study groups, have developed further at universities around the world (Capstick, 2004; Dawson, van der Meer, Skalicky, and Cowley, 2014; Sole et al., 2012). Typically, PAL study groups are offered to first-semester students as a supplement to the formal teaching provided by teachers, and organized as classroom-based sessions in small groups led by near-peers, who are trained students with one or more years’ experience compared to the learner (Capstick, 2004; Topping, 1996).

Theoretical basis of peer assisted learning

The PAL study groups are based on social constructivism (Jacobs, Hurley, and Unite, 2008; Stigmar, 2016) and theoretical principles of collaborative learning (Jacobs, Hurley, and Unite, 2008). Collaborative learning is rooted in Vygotsky’s (1978) learning theory and his concept of the zone of proximal development. This zone is the distance between the student’s actual and potential level of development (i.e. the zone between where the student can solve problems independently and the level where problem solving can only be mastered through adult guidance, or in collaboration with a more capable peer) (Vygotsky, 1978) such as a PAL leader. Vygotsky (1978) focused on the notion that knowledge and understanding are constructed in dialogue and collaboration within an interactive social context rather than just through independent work (Jacobs, Hurley, and Unite, 2008; Vygotsky, 1978). Furthermore, as near-peers have a better understanding, or a higher ability level than the learner while remaining close to the learner’s level, they may bridge the zone of proximal development more easily than an expert, or a teacher who’s reasoning may be more automatic and subconscious (Topping, 2005; Vygotsky, 1978). This is also relevant in the process of “scaffolding,” understood as a temporary adaptive support in the learning process that is provided until a novice is able to solve the task independently (Wood, Bruner, and Ross, 1976). Hence, by facilitating active learning (i.e. stimulating dialogue, engaging in activities, or simulating real life situations) PAL leaders can provide the necessary “scaffolding” for student learning, collaboration, and the construction of knowledge to effectively take place in their study group (Jacobs, Hurley, and Unite, 2008). The idea that learning takes place in a social community is further emphasized in social cognitive theory by Bandura (1986) and in sociocultural learning theories by Lave and Wenger (1991). The latter two coined the term “community of practice” (Lave and Wenger, 1991) which was further developed by Wenger (1998, 2011) and defined as “groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly” (Wenger, 2011). In addition and in line with Bandura (1986) PAL leaders may become important role models for first-semester students.

Peer assisted learning study groups in higher education

Various forms of PAL have been implemented and reviewed in numerous educational disciplines and subjects, such as finance, law, engineering, computer science, history and sociology, as well as in nursing, medical and allied health professional education (Brierley, Ellis, and Reid, 2022; Burgess, McGregor, and Mellis, 2014; Capstick, 2004; Guraya and Abdalla, 2020; Sevenhuysen et al., 2017; Stigmar, 2016; Stone, Cooper, and Cant, 2013; Zhang and Maconochie, 2022). A range of benefits from PAL have been reported for students for example: improving academic performance (Brierley, Ellis, and Reid, 2022; Dawson, van der Meer, Skalicky, and Cowley, 2014); and helping with the adjustment to university life, and improving study skills (Capstick, 2004). Other important benefits are the less hierarchical relationship between PAL leaders and students than between teachers and students. PAL leaders are more approachable, and might therefore be in a better position creating a safe and non-evaluative environment where students feel that they are more capable to ask questions and admit knowledge gaps (Capstick, 2004; Field, Burke, McAllister, and Lloyd, 2007; Stigmar, 2016; Topping, 2005). These benefits can be related to cognitive and social congruence, which is created by the near-peers and the students sharing a common and similar knowledge base and the same social roles (Lockspeiser, O’Sullivan, Teherani, and Muller, 2008; Schmidt and Moust, 1995).

In physiotherapy education, hands-on clinical skills have traditionally been regarded as physiotherapists’ core competence (Luginbuehl et al., 2023) and the dominating teaching strategy has been live demonstration of skills by an expert, or a teacher followed by students practicing the demonstrated skill in pairs (Ivey and Parrish, 2022). In this learning approach, the teacher is at the center of attention (Luginbuehl et al., 2023) which in the field of physiotherapy education may have contributed to less focus on peer learning. Still, previous studies have investigated PAL in physiotherapy education related to clinical placements or simulation-based learning (Dennis et al., 2020, 2022; Mandrusiak et al., 2014; Paparella-Pitzel, Anderson, Rothpletz-Puglia, and Parrott, 2021; Sevenhuysen et al., 2013, 2014) and undergraduate courses with peers from the same year (Asghar, 2010; Hammond, Bithell, Jones, and Bidgood, 2010). Two studies have investigated study groups led by near-peers, focusing on either the student perspective (Sole et al., 2012) or the group leader perspective (Unger, Keiller, Inglis-Jassiem, and Hanekom, 2014).

Peer assisted learning study groups in a bachelor program in physiotherapy

The Oslo Metropolitan University, Norway (OsloMet) implemented a new study plan for the bachelor program in physiotherapy in 2020, and 220 students are admitted to the program each year. With such a large student cohort, the academic staff have experienced a greater distance between the students and themselves as teachers. To support the students’ transition into the bachelor program, PAL study groups were offered to all first-semester students enrolled to the course “Function – Examination and Assessment Tools” (15 ECT; European Credit Transfer and Accumulation System) Autumn 2021. The learning outcomes in this course addresses basic competences required to examine, assess, and identify factors that promote and hinder functioning and health. The PAL study groups were implemented in accordance with the PAL scheme developed by the Learning Support Center at OsloMet, which is based on known principles for SI/PAL study groups (Capstick, 2004). However, while typical PAL sessions review course content (Capstick, 2004), the PAL sessions in our course included both theory and the opportunity to practice manual skills, which is reflective of the nature of the course having practical skill training as part of formal teaching. Attendance was voluntary, and the PAL sessions were self-organized, as each group jointly decided what to work on based on the students’ needs related to lectures, skills training, the syllabus, and assignments. Although Sole et al. (2012) previously investigated voluntary peer-led study groups in physiotherapy education, they investigated study groups with a main focus on manual skills implemented in the second academic year, and only from the perspective of students participating in the peer led study groups. As adjustment to university life can be challenging for new students, especially in large classes (Boud, 2001) investigating the implemented PAL scheme, from both the students’ and PAL leaders’ perspectives, will contribute to a better understanding of PAL study groups in physiotherapy education. In this study, we aimed to gain in-depth knowledge of physiotherapy students’ and PAL leaders’ experiences with a PAL scheme of voluntary, peer-led study groups in the first semester of a bachelor program with many students.

Methods

Organization of peer assisted learning study groups

In August 2021, voluntary, peer-led study groups were offered to all students enrolled in the course “Function – Examination and Assessment Tools (FYB1000). All students (n = 220) were randomly divided into 10 small student groups ranging from 20 to 22 students for teacher led seminars and manual skills training that were mandatory. These groups also constituted the PAL study groups, in which third-semester students (PAL leaders) led the PAL study group sessions. The PAL leaders were paid through financial support allocated by the Norwegian Ministry of Education and Research. This financial support was given to public universities during the COVID-19 pandemic to support the academic follow-up of students. All PAL leaders were trained for their role during an intensive, six-hour initial training course, developed and led by assistant professors from the Learning Support Center at OsloMet. The PAL leaders worked in pairs and were responsible for two of the 10 study groups. During autumn 2021 they led five 2-hour seminars for each group. Attending the PAL seminars were voluntary, and the first-semester students could freely choose which and how many seminars they wanted to attend.

Study design and participants

Focus group interviews (FGIs) were found suitable for exploring shared experiences with PAL study groups, from both the students’ and PAL leaders’ perspectives. We invited all students enrolled in the FYB1000 course and all 10 PAL leaders to participate in the study. To be included, the students had to have participated at least once in a PAL study group session during autumn 2021. We recruited students through announcements on our online learning platform and when meeting them face-to-face in class. The PAL leaders were invited to participate via an e-mail sent to their student e-mail account. Because we focused on the experiences of being in a PAL study group, only students who participated in these groups were included. The study protocol was approved by the Norwegian Center for Research data (ref # 235543). All participants were informed about the study’s purpose. We emphasized that participation in the study was voluntary and withdrawing would have no consequences for further studies at the university. Each participant gave their written informed consent prior to participation. During the FGIs, we attempted to include all participants and acknowledge their ideas, thoughts, and contributions. To protect the privacy of all students and PAL leaders who were part of the PAL study groups, we asked the study participants not to name peers or PAL leaders or give sensitive information about themselves. Moreover, to protect participants’ privacy, all data were stored encrypted and processed in accordance with the research rules and guidelines at OsloMet.

Based on the literature on PAL in higher education, particularly in health care programs the research team developed two interview guides for the: 1) students; and 2) PAL leaders (Appendix). The FGIs were guided, by the open-ended questions regarding the participants’ experience with the PAL seminars, the learning environment, and the academic and social benefits of the PAL study groups. All FGIs was planned to take about 60 minutes and were audio recorded using the “Nettskjema-dictaphone” (University of Oslo) a dictaphone app for recording audio encrypted on smart phones.

Analysis

The data from the FGIs were subjected to thematic analysis inspired by Braun and Clarke (2006) and their principle of identifying, analyzing, and reporting patterns in a transparent way. In the process of analyzing the empirical data, the study authors met for four workshops. Prior to these workshops, the authors read the transcripts individually to form an overall impression of retrieved data. In the first two workshops we discussed our general impressions, highlighting noteworthy themes we found important in relation to the overall research question. After these sections the first author coded each interview by hand. Furthermore, in the two last workshops, we used a white board to write down the codes, to discuss and organize the themes and subthemes in an interpretative way. This included many rounds and discussions moving back and forth in the entire data set (i.e. repeated reading). Finally, four themes were generated mirroring important patterns related to the research question; we found vivid quotations in the transcripts that demonstrated our analytical points. In the last phase the analytic narrative was written by the first and the last author, whereas the second author was commenting on several drafts.

Results

Five interviews were conducted in the first quarter of 2022, in which 23 participants shared their experiences of being involved in a PAL study group. We included 15 students divided into three FGIs. Eight of the 10 PAL leaders participated in two FGIs, as two leaders were prevented from participating. Participants were both women and men, aged 18 to 33. In the following section, the results are structured within four main themes.

Main theme 1: an overwhelming transition - eased by PAL study groups

The students expressed that entering university was overwhelming and that the transition from upper secondary school to university studies was particularly challenging. Many students were new to the university community, new in the city, and had few acquaintances. Large classes and limited contact with the teachers made them feel that they were largely left on their own. These feelings were also reflected in the PAL leaders’ sentiments.

It was overwhelming to start [in the physiotherapy program], especially when you haven’t studied before, or don`t have input from another health professional background.

(FGI 4, PAL leader 3)

In addition to being new as a student, they also expressed challenges with keeping track of the scheduled course progress.

I was overwhelmed. Everything was new and we started right in with anatomy and functional assessment. I felt I was constantly lagging behind and somehow couldn’t close the gap. I was alone and only talked to people when in class, so I didn’t understand that everyone else was in the same situation. To get there [PAL study group], you heard everyone was in the same boat.

(FGI 2, Student 10)

As the above quotes illustrate, entering the PAL study group was an important step to socialize with other students, to feel less alone, and to feel as though their overwhelming feelings were validated. The students expressed that the PAL study group was easy to enter, and they largely agreed that PAL was an important arena in which to build a social network and avoid isolation. Being part of a PAL study group was also a facilitator for finding other students to work with in a more systematic and organized way, for example in a colloquium group (i.e. a small, self-organized study group).

I also think PAL was very good, because there were some in the class who didn’t have a colloquium group, or someone to read with. There were several of them who joined [the PAL study group]. Thus, PAL was an entrance ticket to find someone to work with.

(FGI 3, Student 15)

It was very important to work with people who were in the same colloquium group. It helped a lot; I don’t think I would have managed it [the studies] without it [colloquium group]. So maybe it’s important to build a social network from the beginning. And I don’t think we’ve been given many opportunities through school.

(FGI 3, Student 14)

As these quotes indicate, the students found that the PAL study group was a unique arena in which to meet fellow students. Being part of a community at the university was generally perceived as a key factor for a positive start as a student, and thus crucial for learning and study progression.

Main theme 2: the significant role model - creating safe learning environment

To recognize and be recognized when entering the PAL group was emphasized as significant, and both students and PAL leaders talked about how the PAL leaders became role models for the first-semester students. The PAL leaders highlighted that they could motivate and inspire the first-semester students in their learning process just by being in the same life situation as them: being a bachelor student, about the same age, and sharing some of the same interests.

They can be reflected in us in a way: a year ago we knew nothing, only a year later we know a lot. It can be motivating.

(FGI 4, PAL leader 1)

Maybe they [the students] feel it [the PAL leaders’ view] is more credible because we’re talking from experience. Meanwhile, the teachers trained a long time ago and things have changed. We’ve just done it, so we know better what they’re going through. And, we aren’t teachers, not authoritarian. We aren’t as scary. We’re in the same place, just a little ahead.

(FGI 5, PAL leader 8)

The above remark shows how the PAL leaders identified their role as different from that of the teachers. The PAL leaders seem to have a closer relationship with the students than the teachers. Interestingly, from the FGIs, it is evident that the PAL leaders also became role models for the first-year students simply by virtue of being students who had progressed in their studies. The PAL leaders’ experiences and reassuring demeanor made them seem trustworthy. Interestingly, the quotes also suggest that being a role model involved various aspects such as motivation, inspiration, and trust. Credibility was also highlighted when the students talked about the relationship in-between themselves and the PAL leaders.

“When you have that uncertainty and you ask someone who’s been through the same thing, who says “We had exactly the same thing and it went just fine with all of us.”

(FGI 1, Student 1)

“That’s a little safer to hear from a student who’s just been there than a teacher who somehow say, ‘You can do it.’ They are very different inputs to get.”

(FGI 1, Student 3)

For the students, being part of a community of mutual understanding seemed to be a first step toward feeling as though they were in a safe learning environment. As the quotes above demonstrate, hearing from students similar in age and experience that becoming a physiotherapist was achievable was more convincing than the support provided by teachers. A more symmetrical “power balance” between students in different semesters, seems to be more easily achieved than between students and teachers, and may be viewed as a significant factor in creating a safe learning environment.

With a teacher I feel like I can’t ask everything. It feels like there’s some distance. Maybe like a difference in power.

(FGI 3, Student 14)

We sat down and discussed with them [the students]. Because, then we got rid of that fear, or that power imbalance.

(FGI 4, PAL leaders 5)

Overall, both students and PAL leaders perceived the role of the PAL leaders as quite different from that of the teachers. The deconstruction of the asymmetrical teacher-student relationship resulted in a different foundation for learning. The PAL leaders generally perceived that their role was to support and guide the students, as well as to facilitate student activity and a safe learning environment. They tried to facilitate discussions by approaching the students in ways that reduced fear and the power imbalance and helped the students through scaffolding. This kind of behavior likely contributed to the relaxed atmosphere described by the students and their perception of a safe learning environment.

Main theme 3: building a bridge between theory and practice through scaffolding

The students and PAL leaders had all encountered an unknown field of knowledge as new physiotherapy students, and thus had a common understanding of the experience. The students expressed that topics in physiotherapy were very different from those in upper secondary school and that topics like clinical assessment, anatomy, and biomechanics involved learning a new language, requiring new terminology.

This course is quite different in what and how to learn compared to upper secondary school subjects. This is theory and practice, which don’t work without each other, and in a whole new language they haven’t spoken.

(FGI 4, PAL leader 5)

We were a little stunned, okay. Someone has to explain it [biomechanics] slowly to us. Someone who can explain it in our green [beginner] language.

(FGI 3, Student 13)

As the quotes indicate, most students needed support in acquiring the understanding and use of anatomical terms derived from ancient Greek and Latin words, as well as basic knowledge of biomechanics.

In addition, several students expressed that they were concerned with how they should learn the course content. In response, the PAL leaders shared their study techniques and learning strategies, as well as personal tips and tricks. They also adjusted their language and explained topics in different ways to accommodate the students’ competence level.

When there were questions about biomechanics, we tried to stand and show and explain and use our bodies when it came to both axes and [movement] planes.

(FGI 5, PAL leader 7)

We [the students] worked on movement planes and found pencils that we poked each other with to demonstrate. So yeah, they [PAL leaders] kind of brought it down to a level that we could understand.

(FGI 2, Student 10)

These quotes show that the PAL leaders helped the students to understand the new knowledge using kinesthetic and tactile learning strategies. This might imply that learning about bodily movements was experienced intuitively, within the body.

The students also reported that they did not know what questions to ask in class, particularly at the beginning of the semester. They valued that the PAL leaders helped them to identify relevant topics to work with and discuss. Further, some students said that they wanted more guidance on what to prioritize from the course content and how to work with the learning activities. They suggested that the PAL sessions should be led more by the PAL leaders and be less dependent on the students themselves choosing what they wanted to work on. Nevertheless, the students reported that their ability to self-direct their learning increased during the semester, and they particularly valued working with learning activities; these included planning and providing a basis for clinical assessments in simulated patient cases.

We were asked by the teachers to work on the patient cases, but when I looked at them it was like: What should I do with these? I didn’t know where to start. In my PAL class, we worked through the cases. Step by step.

(FGI 2, Student 10)

As illustrated in this quote, both students and PAL leaders emphasized the importance of breaking complex topics into smaller segments. For example, the PAL leaders used theoretical models such as the International Classification of Functioning, Disability and Health (ICF) (World Health Organization, 2001) when discussing relevant assessment and clinical reasoning in the simulated patient cases. By categorizing the given patient information, the students and PAL leaders worked together to identify different pieces of information, which guided them in what information a therapist would need to ask a patient.

I didn’t think of identifying ICF [categories] at first [when working with the patient cases], but it was very clever because then it’s much easier to plan a clinical examination and know what to ask about in the medical history. It was much easier when you got tips along the way.

(FGI 1, Student 5)

Through the formal teaching, the ICF model is introduced by lecturing, and the further understanding and use of ICF is followed up by seminars and skill training using simulated patient cases. As indicated by the quote above, working in parallel with the ICF in a PAL setting seemed to facilitate deep learning of the model and its utility in a clinical physiotherapy setting, thus, building a bridge between theory and practice.

Although the FYB1000 course focused heavily on manual assessment techniques, most students did not practice their manual assessment skills in the PAL sessions. They said that they did not understand the importance of practicing manual skills until closer to the course exam or that they deliberately chose to focus on parallel courses. The PAL leaders said that they initially expected the students to focus more on skills training, but that during the PAL sessions, they recognized that their own understanding had been at the same level when they were in their first year. In response, the PAL leaders tried to help students to see how different bachelor courses were connected. They found that the simulated patient cases helped them to bridge knowledge from courses running in parallel and making the knowledge relevant to future practice as a physiotherapist.

When you have learned about hip anatomy, it’s a good idea to connect it [the anatomy] to the hip cases [simulated patient cases] and think about muscles in relation to testing.

(FGI 4, PAL leader 7)

It helps to connect and see the whole. Okay, so we do hip flexion, or AROM [active range of motion assessments]: What happens in the joint and in which planes [anatomical planes of motion]? Just connecting [the knowledge] a bit like that.

(FGI 4, PAL leader 6)

The students described a range of learning strategies when learning new knowledge. Several preferred to read the course literature and work individually with different reading strategies to learn the content. Most learned best when discussing or working with others, and by joining a PAL study group, the students gained access to a collaborative form of learning.

We worked with the patient cases in groups. How they [the PAL leaders] discussed it and brought it together highlighted the importance of discussing with others, don’t just do everything on your own. To get a different view of things.

(FGI 1, Student 6)

This remark shows that the students experienced benefits from sharing their views and discussing with peers when working with simulated patient cases. The students described how the PAL leaders facilitated discussion, reflection, and reasoning among the students. As the PAL sessions progressed, the students became more independent and better able to connect and integrate different knowledge bases and perspectives. The PAL leaders also had more knowledge and experience from clinical placements and could bring in the perspective of real patients. Overall, the PAL leaders helped the students to adopt the new language and build a bridge between theory and practice, as well as contextualize new knowledge for future patient encounters.

Main theme 4: time to mature and filtered knowledge

In general, the students experienced a heavy workload throughout their first semester. New topics were constantly introduced during the first semester, and the students described having little time to process and review the content within the timetable for the compulsory training. Hence, the PAL study groups provided valuable time in which to review. Some students particularly appreciated having a specific time for the PAL study group scheduled into their timetable, as this helped them manage their study time. The PAL leaders also emphasized the importance of time, but they focused on time as an important factor in understanding knowledge related to functional assessment.

The subject needs to mature. The thought process of what they want to do when they have a patient, and when they read a patient case, or some information, or just start thinking about what they want to do and so on - I feel it’s something you must understand in a way and not just cram.

(FGI 5, PAL leader 8)

Moreover, time was also related to the student’s perception of a generally relaxed atmosphere in the PAL study groups. The students said that, in the PAL sessions, they had the time to work at their own pace, as well as the opportunity to ask the same question several times without feeling like they were wasting their fellow students’ time. They also valued that the PAL study group was an arena where they could ask any questions that they had regarding the course content.

“Important to me was that they [the PAL leaders] could tell what was relevant. When you ask questions in PAL, they don’t say that everything is equally important but can in a way distinguish what will most likely come on the exam—sort it out a bit. If you ask a teacher, they almost have to say; “You must know all of this.”

(FGI 1, Student 2)

I think we had knowledge that was filtered in a way.

(FGI 4, PAL leader 5)

As evident in the quotes, both students and PAL leaders acknowledged that the PAL leaders could provide a type of filtered knowledge and help the students to sort out what was likely to be important on the course exam. The PAL leaders also helped the students approach the learning outcomes.

To be completely honest, I didn’t read the learning outcomes at first. It was a bit like a foreign language.

(FGI 2, Student 8)

I think there are many who agree with that. From upper secondary school, people are used to getting the learning outcomes at the very start, but then you don’t think about them anymore. Here [in the FYB1000 course], the learning outcomes are helpful in the run-up to the exam.

(FGI 2, Student 10)

In many of the PAL study groups, students also simulated the practical and oral course exam, under the guidance of the PAL leaders; they experienced that, by focusing on the learning outcomes and practicing the exam situation, they felt safer and better prepared for the exam itself.

Discussion

In this study we found that joining a PAL study group was an important step for new physiotherapy students to adapt to life at university. Our finding that the students experienced the first semester as overwhelming resonates with previous reports that the transition from upper secondary school to university studies may be particularly challenging for new students, as the university learning environment offers less structure and requires more self-direction, often in large classes (Boud, 2001; Strømmen-Bakhtiar, Helde, and Suzen, 2021). Importantly, we found that the students felt left on their own, believing that they were the only ones who were struggling to master the new learning situation. However, joining a PAL study group greatly reduced students’ stress level, as they understood that they were not alone, and their feelings were reflected by others in their cohort and the PAL leaders. Although the social benefits of PAL have been described previously (Capstick, 2004; Hammond, Bithell, Jones, and Bidgood, 2010; Meyer, Haukland, Glomsås, and Tveiten, 2019; Sole et al., 2012) we found that the PAL study group was an arena for social interaction with peers, while also being a safety net for students who had not yet found social belonging among their fellow students. Although all students were encouraged by staff members to form colloquium groups, some students were still left out. The PAL study group functioned as an important collaborative and inclusive learning community available to all students.

Joining a PAL study group was described by the students as becoming part of a community of mutual understanding which seemed to be a first step for them to feel like they were in a safe learning environment. The importance of a safe and collaborative learning environment is in line with previous literature on PAL (Boud, 2001; Capstick, 2004; Carr et al., 2016; Hammond, Bithell, Jones, and Bidgood, 2010; Sole et al., 2012; Topping, 1996). The PAL study group can be seen in light of Lave and Wenger (1991) concept of “community of practice,” and its three key elements domain, community, and practice (Wenger, 1998, 2011). First, the group has a common identity through a shared domain of interest (i.e. becoming a physiotherapist). Second, as the students and PAL leaders pursue their interest in this domain, they engage in joint activities and discussions, share information, and help each other; these interactions are essential to making the PAL study group a community, in which members build relationships that enable them to interact and learn from each other. Finally, members of a PAL study group are all physiotherapy students who develop a shared repertoire of resources through the study group (i.e. experiences, knowledge, and study techniques relevant to complete their degree and become physiotherapists); the members of the PAL study group may thus be seen as practitioners sharing their practice. Being part of a community of practice and engaging in group processes, such as in a PAL study group, is highly relevant for future healthcare professionals who will need to work collaboratively (Asghar, 2010).

Through the lens of Bandura’s (1986) concept of role models, we found that the PAL leaders motivated the students as they were one step closer to their goal: namely, to complete the bachelor’s degree and obtain authorization to practice as a physiotherapist. The PAL leaders’ experience of having “been there, done that” likely gave them credibility, since they knew what was needed to master the course and the upcoming exam. In line with previous literature (Field, Burke, McAllister, and Lloyd, 2007; Sole et al., 2012) both students and PAL leaders perceived PAL leaders to be more approachable than teachers. Our findings also indicate that some aspect of the student – teacher relationship may hinder a good learning environment, such as student reluctance to ask questions for fear of revealing limited knowledge, or waste fellow students’ time, students feeling like they are being assessed by the teacher, and an asymmetric power balance. These findings may be related to cognitive congruence. As the students and the PAL leaders share a similar knowledge base, the PAL leaders may easily understand the students’ cognitive problems and needs, and thereby explain topics at a level and in a language the students can comprehend (Lockspeiser, O’Sullivan, Teherani, and Muller, 2008; Loda et al., 2019; Schmidt and Moust, 1995; Ten Cate and Durning, 2007). In addition, the PAL leaders and the students share similar social roles, such as being physiotherapy students, representing social congruence (Lockspeiser, O’Sullivan, Teherani, and Muller, 2008; Schmidt and Moust, 1995). We found that the PAL leaders demonstrated social congruence by being interested in students’ needs, workload, and daily life, as well as by communicating informally, which is in line with a recent scoping review (Loda et al., 2019). Overall, our findings show that the PAL leaders fulfilled a different role than that of the teacher, and that having role models was important for student success. Moreover, as there is less contact between the individual student and the teacher in large classes (Boud, 2001; Stigmar, 2016), it seems plausible that students will experience a greater distance between themselves and the teacher. Therefore, the PAL leaders may become even more important in courses with many students.

Our findings show that the PAL study group was an important arena for peers to communicate in their new, professional language and according to Vygotsky (1978) experience cognitive development, as they used language to express their growing awareness and understanding of a topic. Interestingly, we found that non-verbal communication was also important for students when learning anatomy and biomechanics. They enhanced their learning through kinesthetic and tactile forms of communication (i.e. moving their bodies and using pencils to visualize the axis of rotation in human joints). “Learning by doing” is especially important for kinesthetic learners, who typically learn by carrying out a physical activity rather than reading, listening, or watching (Fleming and Mills, 1992; Murphy, Gray, Straja, and Bogert, 2004). As body, movement, and function are important knowledge fields of physiotherapists (Kordahl and Fougner, 2017; Wikström-Grotell and Eriksson, 2012) enhanced learning about the body within the body (Kordahl and Fougner, 2017) appears to be an important and clinically relevant learning experience for physiotherapy students. However, the bodily experience described by the students displays a biomedical focus. Clinical expertise in professional physiotherapy requires knowledge of different scientific approaches (Kordahl and Fougner, 2017; Nicholls and Gibson, 2010, 2012) and the concepts of body, movement, and function in physiotherapy is multidimensional, including physical, emotional, sociocultural, and existential dimensions (Nicholls and Gibson, 2010, 2012; Wikström-Grotell and Eriksson, 2012). The students’ one-dimensional focus might reflect that physiotherapy competence is unfamiliar to most new students, and that they must focus on one topic at a time before integrating multiple perspectives. Interestingly, the PAL leaders were able to simplify and explain sub-components, as well as guide students to bring cross-disciplinary knowledge together and integrate different perspectives from real-life situations. Following Vygotsky (1978) our findings suggest that the PAL leaders were able to guide the students in their zone of proximal development, as well as to continuously adapt their level of guidance to the students’ increasing level of knowledge.

The PAL leaders also facilitated active learning by stimulating dialogue, reflection, and collaboration; they provided “scaffolding” for the students’ learning and construction of knowledge (Jacobs, Hurley, and Unite, 2008; Wood, Bruner, and Ross, 1976). The importance of “scaffolding” was particularly clear in learning activities where the students had to plan and justify a relevant functional assessment for different patients in the simulated patient cases. In accordance with previous literature (Asghar, 2010; Sole et al., 2012) we found that working with simulated patient cases improved the students’ understanding of assessments and tests, as well as their ability to reason around a comprehensive clinical assessment for the patient cases. Moreover, our findings indicate that the PAL leaders’ guidance amplified the students’ learning, and it helped the students to contextualize and authenticate the importance of competence in clinical assessment as a physiotherapist. In this way, the PAL leaders may have facilitated a nascent identity as future physiotherapists among the students.

Our findings also show that time was an important element for learning. The scheduled PAL sessions helped students to manage their own study time and offered them a non-stressful period in which they could revise what they had learned, which is supported by previous literature (Capstick, 2004; Sole et al., 2012). The PAL leaders ensured that the students had sufficient time to work on topics they needed to focus on and allowed time for the students’ new knowledge to mature. Interestingly, we found that the PAL leaders also helped the students by acting as a filter to sort out what was more or less important for the exam. One might question whether filtered knowledge promotes a one-sided focus on exam performance at the expense of in-depth learning. At the same time, it seems necessary to deprioritize some themes, to achieve deep learning in others. Nevertheless, since filtered knowledge probably increases the focus on exam performance, the pedagogical principle of constructive alignment appears particularly important. Following Biggs and Tang (2015) if the teaching and assessment methods are aligned with the learning outcomes that students are expected to achieve, filtered knowledge and a focus on exam performance can be beneficial when learning clinical assessment and reasoning. Furthermore, rehearsing the exam situation in the PAL sessions can also promote students’ ability to reflect on and assess their own and fellow students’ performance. For students to be able to assess their own or peers’ performance, they need to be very clear of the learning outcomes and exam criteria (Biggs and Tang, 2015). Our findings indicate that the PAL leaders actively aided in knowledge translation and facilitated the students’ ability to make judgments about whether a performance met the learning outcomes and given criteria. As professionals need to assess their own and their peers’ performance and identify how their performance can be improved (Biggs and Tang, 2015) PAL study groups arguably facilitate lifelong learning skills. Lifelong learning is the ability to engage in learning activities throughout life, to improve knowledge, skills, competences, and qualifications (Organization for Economic Cooperation and Development, 2021); its importance is further emphasized by the fact that it has become the overarching concept and vision of higher education institutions worldwide (UNESCO Institute for Lifelong Learning, 2022).

Strengths and limitations

Focus group interviews are perceived to be suitable when you aim to explore shared meanings, experiences, and attitudes (Wilkinson, 2011). A disadvantage of using FGIs is that they generate a small sample size which may limit the generalizability of the findings. However, FGIs do not seek representativeness but rather to explore discussions and perspectives around a topic, such as PAL. In the FGIs, the researchers aimed to facilitate open discussions, which allowed the participants to communicate their immediate reflections. Furthermore, we acknowledge that we are missing the perspectives of those who chose not to attend in the PAL study groups, but the focus of this study was the experiences of those who participated in such a group.

All students in the first year of the bachelor program in physiotherapy at OsloMet, Norway, were invited to participate in this study. The participants were heterogeneous according to age, gender, and previous study experiences. Nevertheless, those who found participation in the PAL study group to be beneficial may have been more likely to participate in this study; selection bias may therefore be a limitation. Since we were aware of this, we encouraged the participants to also reflect on negative aspect of participating in PAL study groups. Another limitation may be the fact that an associated professor at OsloMet, who implemented the PAL scheme and was one of two teachers responsible for the FYB1000 course, assisted with all the FGIs. Although it was explicitly stated prior to the interviews that the participants could discuss freely, this might have resulted in information bias, as participants may have been reluctant to make negative statements. Nevertheless, the interviews were led by an experienced qualitative researcher who did not know the students, and we believe this helps to mitigate the risk of information bias.

A strength of this study is that we interviewed both students and PAL leaders, which enabled us to explore different perspectives and thus enhance our understanding of the PAL scheme. Moreover, to ensure transparency of the study, we have tried to make all the steps in the study as explicit as possible.

Conclusions

This study explored students’ and PAL leaders’ experiences with and reflections on voluntary PAL study groups in the first semester of a bachelor program in physiotherapy with many students. Overall, we found that PAL study groups formed an important community of practice and that the PAL leaders served as important role models, providing academic, social, and emotional support for the first-semester students. Working with simulated patient cases seemed particularly beneficial for bridging theory and practice in learning clinical assessment and reasoning, and the PAL leaders provided the necessary “scaffolding” for the first-semester students’ learning, collaboration, and construction of knowledge. In addition to professional skills, the PAL study groups seemed to promote generic skills relevant for lifelong learning. Our findings provide a more in-depth understanding of PAL study groups in physiotherapy education and support that PAL study groups, as a supplement to formal teaching, are important to aid new students in their transition to the university environment and studies, particularly in courses with many students.

Acknowledgments

We would like to thank all the participants and Grethe M. Johansen and Ingunn Nilsen at the Learning Support Center at OsloMet University for their assistance in implementing peer assisted study groups in the bachelor program in physiotherapy. We acknowledge the Norwegian Ministry of Education and Research for the financial support allocated to government universities to pay students for the academic follow-up of other students, cf 233S (2020-21) and Prop. 89 S (2020-21).

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Appendix

Attachment 1: Interview Guide for the Students Who Attended PAL Study Groups

Introductory information

• Purpose of the study

• Some guidelines (let everyone speak, no right or wrong answers)

• We kindly ask everyone not to provide the following information during the discussions/focus group interview:

  • Sensitive personal information about yourself or others (e.g. health information, sexual orientation, and legal violations)

  • Names of fellow students in the PAL study group or PAL leaders

Learning

Can you tell us about your sessions with the PAL leaders? What did you do? What was the role of the PAL leader?

Was there anything significantly different about the PAL leaders compared to other teaching methods you’re familiar with? (provide examples)

Can you give some examples of particularly effective learning situations?

Do you have any examples where things suddenly clicked for you with the PAL leaders?

Can you give some examples of when it didn’t work as well?

What constitutes a good learning process for you (i.e. how do you acquire knowledge most effectively)?

In what ways did you feel the PAL leaders helped you in the learning process regarding skills? Do you have specific examples?

In what ways did you feel the PAL leaders helped you in the learning process regarding writing? Do you have specific examples?

In which situations/how do you learn best?

Safety

A safe learning environment is important for promoting learning. What does a safe learning environment mean to you?

How was this experience for you in the sessions with PAL leaders?

Were there any situations that felt unsafe/especially secure? Can you provide specific examples?

Discuss the statements

PAL leaders are better at helping us in the learning process to be well-prepared for exams.

Teachers are better at helping us in the learning process to be well-prepared for exams.

If you were to give the pal leaders some advice on doing something differently next time, what would it be?

Is there anything we have forgotten? Anything you would like to add?

Attachment 2: Interview Guide for PAL Leaders

Introductory information

• Purpose of the study

• Some guidelines (let everyone speak, no right or wrong answers)

• We kindly ask everyone not to provide the following information during the discussions/focus group interview:

  • Sensitive personal information about yourself or others (e.g., health information, sexual orientation, legal violations, etc.)

  • Names of fellow students in the PAL study group or PAL leaders

Learning

Could you tell us about your experience as PALleaders? What did you do? What was your role as a PAL leader?

How were you prepared to be a PAL leader? How did you feel the preparations equipped you to be a PAL leader?

How did the PAL leader role promote learning in terms of skills?

How did the PAL leader role promote learning in terms of writing?

What do you consider a good learning situation?

Do you have any examples of when you had good learning situations?

Do you have any examples of when you felt the learning situations were not as effective?

Can you provide some examples of particularly successful learning situations?

Were there any aspects you found particularly challenging?

How did you perceive the students’ learning? Describe different learning processes among the students.

Safety

A safe learning environment is important for promoting learning. What does a safe learning environment mean to you?

How did you work to create a sense of safety in the sessions?

Were there any situations that particularly fostered a sense of safety?

Were there any situations where it was more difficult to create a safe learning environment?

Discuss the statements

PAL leaders are better at helping us in the learning process to be well-prepared for exams.

Teachers are better at helping us in the learning process to be well-prepared for exams.

If you could do something differently next time, what would it be?

Is there anything we have forgotten? Anything you would like to add?