J Islamabad Med Dental Coll 2021 23
Open Access
Benefits of Near-Peer Tutoring in Small Group Discussions: A
Pilot Study
Shazia Muazam1, Farzana Majeed2, Saima Mumtaz Khattak3
1Associate Professor, Department of Anatomy, HBS Medical & Dental College, Islamabad Pakistan
2Associate Professor, Department of Physiology, HBS Medical & Dental College, Islamabad Pakistan
3Assistant Professor, Department of Anatomy, Federal Medical & Dental College, Islamabad Pakistan
A B S T R A C T
Background: A year senior medical students can prove to be a useful teaching resource with added benefits for the
tutors. The objective of this study was to explore the perceptions of near -peer tutors after facilitating small group
discussions while delivering an integrated curr iculum in preclinical years.
Material and Methods: This qualitative exploratory pilot study was conducted in Rawal Institute of Health Sciences
Islamabad, Pakistan from July 2017 to November 2017. Students of First year MBBS class (n=100), were divided into six
small groups. Seven Second year MBBS students who had secured more than 60% marks throughout year one
assessments and in Professional examination were selected as Near -Peer tutors after informed verbal consent. In the
first discussion, three groups were taught by three tutors and three by junior faculty. In the second discussion, the
groups were swapped and exposed to the same strategy as above, with new learning objectives, but the remaining
three tutors now took batches. One tutor acted as a substitute. Qualitative data was collected after interviewing the
tutors individually and responses were audio recorded. The collected data, both notes and audio recordings of the
interviews, was transcribed into text to generate codes, theme and sub themes.
Results: Transcription of data revealed that the tutors enjoyed teaching and were of the opinion that Near -Peer tutoring
is more effective in small groups, for both tutors and the learners. The tutors felt a boost in self -confidence and
improvement in communication skills, after facilitating a small group. Tutoring also helped in developing their higher
order cognitive thinking, learning skills and time management.
Conclusions: Near-Peer tutoring helped the tutors develop learning and communications skills while facilitating small
group sessions, thus helping them in their future medical roles.
Key words: Integrated curriculum, Near-Peer tutoring, Peer Assisted Learning, Small group discussions.
Authors’ Contribution:
1Conception; Literature research; manuscript
design and drafting; 2,3 Critical analysis and
manuscript review; Data analysis; Manuscript
Editing.
Correspondence:
Shazia Muazam
Email: shaziamuazam@gmail.com
Article info:
Received: July 30, 2020
Accepted: January 15, 2021
Cite this article. Muazam S, Majeed F, Khattak SM. Benefits of Near-Peer Tutoring in Small
Group Discussions: A Pilot Study. J Islamabad Med Dental Coll. 2021; 10(1): 23-30. Doi:
10.35787/jimdc.v10i1.577
Funding Source: Nil
Conflict of Interest: Nil
I n t r o d u c t i o n
Peer Assisted Learning (PAL) is an instructional
strategy where “learning is through active help of
peer group members”. Peer are the people
belonging to the same social grouping. 1 Near-Peer
OR I GI N A L A R TI C LE
J Islamabad Med Dental Coll 2021 24
Assisted Learning (NPAL) is a variant of PAL in which
the tutor is at least one year senior to the learners in
context of medical training.2 NPAL has been applied
to deliver lectures, tutorials, laboratory practical and
clinical skills formally worldwide.3,4 PAL/NPAL leads
to better cognitive congruence between the
participants.5 The role of tutors is found to be
equivalent to clinicians and nurses in clinical skills
training.6 Peer tutoring nurtures development of
metacognitive, communication and professionalism
skills among the peer tutors.7 They relieve the
burden of teaching from the faculty thereby,
enabling them to take part in productive activities.8
In Pakistan, few PAL studies led to the conclusion
that PAL is as effective as facilitator assisted
learning.9,10 Another national quantitative study
showed that horizontal PAL can actually replace
expert assisted learning in teaching clinical skills to
the undergraduates.11
Small group discussions (SGDs) are a commonly used
teaching strategy in delivering concepts in an
integrated curriculum, worldwide.12 Rapid turnover
and paucity of junior faculty involved in SGDs, affects
the quality of delivery. Clinical experts due to busy
hospital routine cannot justify their roles as teachers
in preclinical integrated modules.13
Scant literature is available on the use of Near-Peer
tutors in SGDs, along with faculty, to deliver
correlational concepts, in an integrated curriculum
in preclinical years. Our study aims to generate
qualitative data on the perceptions of Near-Peer
tutors about NPAL and, their gains after tutoring
small groups to deliver complex integrated
concepts.
M a t e r i a l a n d M e t h o d s
This qualitative exploratory pilot study, based on
theoretical framework of grounded theory, was
conducted in Rawal Institute of Health Sciences,
Islamabad, Pakistan, from July 2017 to November
2017. After approval from the Ethical Review
Committee of Rawal Institute of Health Sciences, the
first year MBBS students were included by
convenience sampling for NPAL intervention. Seven
students of second year MBBS were selected as
Near-Peer tutors by purposive sampling, with the
inclusion criteria set as the students who secured
more than 60% marks throughout year one
assessments and in the professional examination.
Undergraduate students of Dentistry and other
Allied Sciences, and faculty members of Basic and
Clinical sciences were excluded as Near-Peer tutors.
The curriculum in first two years of MBBS is
delivered in three Blocks each, where the Basic
Sciences subjects are horizontally integrated with
each other, and vertically with Clinical Sciences.
Block 2, concerned with integration of upper limb
Anatomy, nerve Physiology, Biochemical and Clinical
aspects, was selected for using NPAL in small groups.
Verbal consent was taken from the tutors after
explaining the study and assuring them of
maintaining their confidentiality by using
pseudonyms in the data analysis. It was clarified,
that out of seven tutors only six would participate in
active teaching, while the seventh would act as a
substitute, in case any tutor could not take the class.
One of them volunteered, himself, for acting as a
substitute. The tutors were given a training session
of two hours by the Principal Investigator (PI) on
different teaching and learning strategies, use of
learning resources, facilitation of small groups and
giving feedback. At the end of the training session,
the tutors were handed learning objectives of both
SGDs, so as to prepare themselves.
The First-year class was divided into six small
groups/batches, A-F with 12 to 15 students in each
batch. Batches A, B and C first attended an SGD
session with the junior faculty while Batches D, E and
F attended the session with three NPAL tutors. The
session lasted for two hours. Both the NPAL assisted
and non-assisted groups had similar learning
J Islamabad Med Dental Coll 2021 25
objectives regarding four nerves of upper limb, their
injuries and correlation of symptoms with the site of
lesion. In second SGD, the batches were flipped and
exposed to the same strategy as above, with new
learning objectives regarding three new nerves.
Those taught by junior faculty in first session were
taught by the remaining three Near-Peer tutors,
while the rest of three small groups were taught by
junior faculty thus, exposing the whole First year to
Near-Peer tutors.
Qualitative data was collected from all six tutors by
holding individual interviews conducted by the PI,
who holds an MPhil degree and is currently enrolled
as an MHPE (Masters in Health Professions
Education) student. The interviews were held and
audio recorded the next day after the second SGD in
the PI office. An interview guide, prepared after
consultation with a colleague and a medical
educationist, in advance, guided the interviewer in
the process. The interview started with open ended
questions, proceeded forward with follow up and
probe questions to make the tutors elaborate their
responses. Notes were taken. Each interview lasted
for fifty minutes, on an average.
The collected data, both notes and audio recordings
of the interviews, was transcribed by PI into text.
The text was read multiple times to draw deeper
meaning. Being a pilot study, the data was small, so
it was analyzed manually. The text was divided into
segments of information. Different colored
highlighters were used to mark familiar texts to
generate codes. Same codes were overlapped or
discarded, thus reducing 30 codes into four themes
depending on their broad meaning and seven
subthemes were extracted from themes. Few
amendments were made after review of raw data by
a non-medical peer. To eliminate researcher bias,
raw data was sent to a medical educationist who
validated the transcriptions, codes, themes and
subthemes. Member checking was done by sending
the text data to the tutors.
R e s u l t s
Analysis of data resulted in emergence of four
themes underlying four categories. Seven
subthemes were extracted from the four themes
(Table I).
D i s c u s s i o n
The tutors involved in our study enjoyed the
experience of teaching in small groups and found it
beneficial for themselves and for the learners. The
first theme highlighted a new aspect where the
tutors developed an insight of pursuing teaching as
a profession. Our Near tutors, initially clinically
oriented, started considering teaching as a
profession, as they were attracted by the
satisfaction which one attains after delivering a
content. The second theme developed as the tutors
felt that NPAL is beneficial for the learners. Near-
peer tutors can understand the hurdles in learning
as both learners and tutors are at the same mental
status, therefore tutors try to overcome them. They
can readily integrate new learning experiences and
techniques into the curriculum.
Different researchers have proved that pairing
junior and senior undergraduate students enhances
psychological support and helps in improving
professional and personal development in both.14
Our tutors guided the learners about different
learning resources and time management. Peer
tutors have been shown to create an atmosphere
that allows learners to exchange ideas in a stress-
free manner.15 Theme three of our study exhibited
that during small group preparation, tutors
developed deeper understanding of the subject
matter thus encouraging them to deliver
confidently. Revisit of previously learnt topics
helped in strengthening their own concepts which
would prove beneficial in their future medical
career.
J Islamabad Med Dental Coll 2021 26
Table I: Categories, themes and few verbatim
CATEGORIES THEMES/ SUBTHEMES
1. NPAL as a
teaching
experience
THEME 1: CONCEPT ABOUT TEACHING
SUBTHEME A: TEACHING IS A SKILL
All six tutors affirmed that their concept about
teaching changed altogether. They had become
aware of the efforts required for conducting a
teaching session and how well prepared a teacher
had to be to answer the queries of the learner.
Three of the tutors, being overwhelmed by the
experience, thought to pursue it as a career
“Teaching is a technique and a skill.”
“The experience was a bit of adventure for
me”
“Teaching was most attractive feature of
this strategy”
“I never felt as if I can think about teaching
as a profession, but after these sessions I
have started thinking about it.”
SUBTHEME B: IMPROVED COMMUNICATION SKILLS
The teaching experience gave them the confidence
to speak in public, thus enhanced their
communication skills. They particularly enjoyed
when they were able to answer the questions asked
by the learners.
“I gained confidence; my way of talkin g
improved.”
“I was unaware of my confidence until now
and felt proud to be able to answer the
queries asked by learners.”
“...communication skills are so much
important I had no idea.”
“I have learned that for one to be a good
teacher one should be a good listener and
have patience.”
2. NPAL as a
learning strategy
for learners
THEME 2: BENEFICIAL FOR LEARNERS
The tutors were of opinion that NPAL is an effective
teaching strategy regarding tutees as first year
students mostly require guidelines about the course
content and time management, which can be best
provided by the ones who have gone through the
same situation only a year ago. Near tutors are also
aware of complex concepts which the learners
usually are unable to understand, so their teaching
is targeted unlike faculty.
NPAL stimulated the learners as they seemed to be
more vocal and interested even at the end of two
hours session.
“I think it is a good learning strategy for
tutees because as a tutor I guided them
about how to use various learning
resources, which topics to focus on; guided
them on time management while
preparing for exam as well as in attempti n g
paper.”
“Even the students who initially seemed to
be uninterested, asked questions at the
end thus showing their interest.”
“If this has been practiced with us, we
would have performed better than this
time.”
J Islamabad Med Dental Coll 2021 27
3. NPAL as a
learning strategy
for tutors
THEME 3: BENEFICIAL FOR TUTORS
SUBTHEME A: DEVELOPMENT OF ABILITY TO DO A COMPREHENSIVE LITERATURE SEARCH
Regarding their own learning experience while
delivering NPAL sessions, all the 6 tutors felt it to be
beneficial for them. While preparing for the sessions
they did not restrict themselves to course books but
used reference books and internet. This enhanc ed
their knowledge which they felt would be very
beneficial in their clinical years.
“I got lots of information regarding content
while searching for the sessions”
“.... because of thorough study while
preparing for lectures I can now relate
many clinical symptoms; the sympto ms
were not explained by the teachers to us
but as I came to know them, I explained it
to the class.”
“The questions put forward by the learners
made me search once again. I consulted
internet for more images to clarify my own
concepts; this was a new experience as I
had never done that before when I was in
1st year; I only read my course books”
SUBTHEME B: DEVELOPMENT OF HIGHER ORDER COGNITIVE THINKING
They also felt that by consulting different learning
resources they could now comprehend the clinical
scenarios with much ease which would help in their
exams while attempting MCQ’s.
They were of the opinion that their concept building
was improved while preparing for the sessions
“After this when I sat for my USML E
preparation it took me less time to solve
the MCQ’s of nerve injuries than I used to
do before.”
“I feel like by being a tutor our approach
will definitely be better than our colleagues
in the clinics.”
SUBTHEME C: EFFECTIVE TIME MANAGEMENT
Two of the tutors were very positive of developing
effective management of their time while preparing
for their sessions.
They realized that by doing clinically oriented study
their Basic concepts were clarified and now could
correlate Basics and Clinical with more ease and in
less time, which would help them in future.
“While preparing for sessions I fixed 15 min
each day out of one hour of my studies for
searching and preparing for NPAL session
thus managed time effectively.”
“Studying the signs and symptoms of nerve
injuries before studying gross anatomy
saved me time to understand the boring
courses of nerves; the images of shapes of
arm and hand due to nerve lesions
enforced the anatomical concepts in less
time”
J Islamabad Med Dental Coll 2021 28
4. NPAL teaching
in small groups
THEME 4: BENEFICIAL IN SMALL GROUPS
SUBTHEME A: EASILY MANAGEABLE
All six of them found it better to conduct NPAL in a
small group as it was easy to handle the learners.
Maintenance of discipline was easy in small groups.
Delivering NPAL lectures would have been difficult
for the tutors and might have not been productive
for learners.
One tutor appreciated the seating arrangements in
small groups which could be readjusted according to
needs.
“Smaller the group lesser the deviation,
more the attention.”
“Even I would suggest to reduce the
number of tutees to 10 for more
effectiveness of NPAL session.”
“I found myself more powerful and
confident while managing a small group.
The students also behaved very well in
small group. I didn’t feel the need to
discipline them.”
“NPAL lecture format will be tiring and
scary at the same time for tutor; it would
be difficult to control a class of 100
students as they have some respect for the
teacher but may not have such feeling for
tutors”
“In the beginning of session, I was a bit
nervous but after seeing a small group my
spirits were boosted; I can’t imagine how
could I have stood in front of whole class? ”
“Altering the seating arrangement in the
small group and making boys and girls sit as
a mixed group will make them concentrate
more on the topic as when they sit with
their friends, they lose concentration.”
SUBTHEME B: EASY AND PRODUCTIVE TRANSFER OF KNOWLEDGE
The tutors found it easy to explain the difficult
concepts and to answer learners’ questions.
Transfer of knowledge was easy due to one -to-one
interaction.
“Giving a MCQ test at the end of smal l
group session is a quick way to assess
knowledge gain by NPA tutoring ......even a
quiz at the end will be very helpful. Such
formative assessments can be easily
applied in small groups and a constructive
feedback can be given appropriately.”
“I thought that it was difficult to make
them understand different hand
appearances in nerve injuries and their
correlation with site of lesion but smal l
group made me ask all the students
individually if they understood or not “
J Islamabad Med Dental Coll 2021 29
It is a known fact that teaching others result in a 90%
retention of material.16 Alveraz and Shultz also
observed that tutoring in Anatomy made the tutors
learn better use of available resources.17 Peer
tutoring increases tutors’ confidence in their own
performance assessments.18 Tutoring experience
provides not only the opportunity to refresh tutor’s
subject knowledge but also develops employability
skills such as leadership, facilitation, project-
management, communication and inter-personal
skills.19 Our tutors felt more confident in
communication and their self-efficacy was enhanced
after answering learners’. It may be because of the
fact that the tutors were one year senior to the
learners but even same level peers had been shown
to develop competency skills.20 Studies on peer
assisted tutoring has been documented to develop
the skills, attitudes and practices of a competent
teacher,20,21 though no studies are found to see the
long-term effect of such interventions on tutors.
A noticeable theme detected in our study is that all
tutors found ‘small groups’ ideal for delivering
complex concepts integration by peer-assisted
learning. From facilitation point of view, our tutors
felt confident when they had to manage small
number of students and it was easy to maintain
discipline. Though large group PAL strategy is more
effective for the tutor as it gives them the ability to
prepare and present in front of a large audience but
lack of feedback and fewer interactions due to less
developed teaching skills are the drawbacks.22
Our study was limited in scope, as being a pilot
study, it was restricted to only two SGDs due to
conflict in scheduling of Near-Peer tutors and
learners’ classes. Thus, the number of tutors was
restricted. It is recommended to conduct such
learning strategy in a whole Block with a number of
different tutors having different academic ranking,
to see the effect of such an intervention on tutors.
We would also recommend to follow-up the tutors
to see the long-lasting effects of tutoring.
C o n c l u s i o n
Students when used as Near-Peer tutors in small
group discussions in preclinical years of medical
school develop strong learning and communication
skills which will be beneficial for them in their future
roles as competent physicians. They can act as an
adjunct resource with faculty, in delivering an
integrated curriculum in small groups.
R e f e r e n c e s
1. Olaussen A, Reddy P, Irvine S, Williams B. Peer -
assisted learning: time for nomenclature
clarification. Med Educ Online. 2016; 21(1): 30974.
Doi: 10.3402/meo.v21.30974 .
2. de Menezes S, Premnath D. Near -peer education: a
novel teaching program. Int J Med educ. 2016; 7:
160-67. Doi: 10.5116/ijme.5738.3c28 .
3. Rosenberg CJ, Nanos KN, Newcomer KL. The “near‐
peer” approach to teaching musculoskeletal physical
examination skills benefits residents and medical
students. PM&R. 2017; 9(3): 251 -7. Doi:
10.1016/j.pmrj.2016.06.004 .
4. de los Ángeles Cambrón-Carmona M, de Lara CNT,
Caracuel IR, Cepas FL, González RG, Lozano SZ, et al.
Near-peer Teaching in Histology Laboratory. Int J
Med Stud. 2016; 4(1): 14-8.
5. Loda T, Erschens R, Loenneker H, Keifenheim KE,
Nikendei C, Junne F, et al. Cognitive and social
congruence in peer-assisted learning–A scoping
review. PloS one. 2019; 14(9): e0222224. Doi:
10.1371/journal.pone.0222224.
6. Abay EŞ, Turan S, Odabaşı O, Elçin M. Who is the
preferred tutor in clinical skills training: physicians,
nurses, or peers? Teach Learn Med. 2017; 29(3): 247-
54. Doi: 10.1080/10401334.2016.1274 262.
7. Clarke AJ, Burgess A, Menezes A, Mellis C. Senior
students’ experience as tutors of their junior peers in
the hospital setting. BMC Res Notes. 2015; 8(1): 743.
Doi:10.1186/s13104-015-1729-0.
8. Khalid H, Shahid S, Punjabi N, Sahdev N. An
integrated 2-year clinical skills peer tutoring scheme
in a UK-based medical school: perceptions of tutees
and peer tutors. Adv Med Educ Pract.2018; 9: 423 -32.
Doi: 10.2147/AMEP.S159502.
9. Sarwar S, Tarique S. Peer-Assisted Learning: Who
Should Be the Tutor, Fellow Student or Senior
Resident. JCPSP. 2016; 26(7): 573 -76. PMID:
27504547.
10. Usman R, Jamil B, Waheed N, Ali L, Ali S, Orakzai N, et
al. Comparison between facilitator and peer assisted
J Islamabad Med Dental Coll 2021 30
learning: an interventional study at Peshawar
Medical College. JPMA. 2019; 69(11): 1588-90. Doi:
10.5455/JPMA.286712.
11. Shah I, Mahboob U, Shah S. Effectiveness of
horizontal peer-assisted learning in physical
examination performance. JAMC. 2017; 29(4): 559 -
65. PMID: 29330977.
12. Ju H, Choi I, Yoon BY. Do medical students generate
sound arguments during small group discussions in
problem-based learning? an analysis of preclinical
medical students’ argumentation according to a
framework of hypothetico-deductive reasoning.
Korean J Med Educ. 2017; 29(2): 101 -09. Doi:
10.3946/kjme.2017.57.
13. Van der Hoeven D, van der Hoeven R, Zhu L, Busaidy
K, Quock RL. Integration of basic and clinical sciences:
faculty perspectives at a US dental school. J Dent
Educ. 2018; 82(4): 349-55. Doi:
10.21815/JDE.018.038.
14. Bugaj T, Blohm M, Schmid C, Koehl N, Huber J, Huhn
D, et al. Peer-assisted learning (PAL): skills lab tutors’
experiences and motivation. BMC Med Educ. 2019;
19(1): 353. Doi: 10.1186/s12909 -019-1760-2.
15. Khalid H, Shahid S, Punjabi N, Sahdev N. An
integrated 2-year clinical skills peer tutoring scheme
in a UK-based medical school: perceptions of tutees
and peer tutors. Adv Med Educ Pract. 2018; 9: 423 -
32. Doi: 10.2147/AMEP.S159502.
16. Ferreira JJ, Maguta L, Chissaca AB, Jussa IF, Abudo SS.
Cohort study to evaluate the assimilation and
retention of knowledge after theoretical test in
undergraduate health science. Porto Biomed J. 2016;
1(5): 181-5.
17. Alvarez S, Schultz JH. Professional and personal
competency development in near‐peer tutors of
gross anatomy: A longitudinal mixed‐methods study.
Anat Sci Educ. 2019; 12(2):129-37.
18. Agius A, Stabile I. Undergraduate peer assisted
learning tutors’ performance in summative anatomy
examinations: a pilot study. IJME. 2018; 9: 93.
19. Burgess A, McGregor D. Peer teacher training for
health professional students: a systematic review of
formal programs. BMC Med Educ. 2018; 18(1): 263.
Doi: 10.1186/s12909-018-1356-2.
20. Nshimiyimana A, Cartledge PT. Peer -teaching at the
University of Rwanda-a qualitative study based on
self-determination theory. BMC Medical Educ. 2020;
20(1): 230. Doi: 10.1186/s12909 -020-02142-0.
21. Donohoe CL, Conneely JB, Zilbert N, Hennessy M,
Schofield S, Reynolds JV. Docemur docemus: peer -
assisted learning improves the knowledge gain of
tutors in the highest quartile of achievement but not
those in the lowest quartile. J Surg Educ. 2015; 72(6):
1139-44. Doi: 10.1016/j.jsurg.2015.07.001.
22. Ningrum R. Students’ perception of peer tutor roles
in the small group discussion. MS&E. 2018; 434(1):
012343. Doi:10.1088/1757 -899X/434/1/012343.