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Crossing professional barriers with peer-assisted learning: Undergraduate midwifery students teaching undergraduate paramedic students
Nurse Education Today 33 (2013) 724–728
Contents lists available at SciVerse ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Crossing professional barriers with peer-assisted learning: Undergraduate midwifery students teaching undergraduate paramedic students Gayle McLelland a,⁎, Lisa McKenna b, 1, Jill French c, 2 a b c
School of Nursing & Midwifery, Monash University, Peninsula Campus, Australia School of Nursing & Midwifery, Monash University, Clayton Campus, Australia School of Nursing & Midwifery, Monash University, Berwick Campus, Australia
a r t i c l e
i n f o
Article history: Received 7 September 2012 Received in revised form 16 October 2012 Accepted 24 October 2012 Keywords: Interprofessional Peer teaching Midwifery student Paramedic student PAL
s u m m a r y Background: Peer assisted learning (PAL) has been shown in undergraduate programmes to be as effective as learning from instructors. PAL is a shared experience between two learners often with one being more senior to the other but usually both are studying within the same discipline. Interprofessional education occurs when two or more professionals learn with, from and about each other. Benefits of PAL in an interprofessional context have not been previously explored. As part of a final year education unit, midwifery students at Monash University developed workshops for second year undergraduate paramedic students. The workshops focused on care required during and after the birth of the baby. Aim: To investigate the benefits of an interprofessional PAL for both midwifery and paramedic students. Methods: Data for this project were obtained by both quantitative and qualitative methods. Questionnaires were distributed to both cohorts of students to explore experiences of peer teaching and learning. Results were analysed using Statistical Package for Social Sciences (SPSS). Focus groups were conducted separately with both cohorts of students and transcripts analysed using a thematic approach. Findings: Response rates from the midwifery and paramedic students were 64.9% and 44.0% respectively. The majority of students regardless of discipline enjoyed the interprofessional activity and wanted more opportunities in their curricula. After initial anxieties about teaching into another discipline, 97.3 (n = 36) of midwifery students thought the experience was worthwhile and personally rewarding. Of the paramedic students, 76.9% (n = 60) reported enjoying the interaction. The focus groups supported and added to the quantitative findings. Both midwifery and paramedic students had a new-found respect and understanding for each other's disciplines. Midwifery students were unaware of the limited knowledge paramedics had around childbirth. Paramedic students admired the depth of knowledge displayed by the midwifery students. Implications: This study indicates both educational and professional benefits for undergraduate students from different disciplines having shared PAL activities. Crown Copyright © 2012 Published by Elsevier Ltd. All rights reserved.
Introduction At the Peninsula campus of Monash University, the nursing building is located directly adjacent to the paramedic building. Yet, there are very few interprofessional activities between the two areas. Students of both the Bachelor of Midwifery and Bachelor of Emergency Health degrees participate together in one science subject per semester in their first year, however only lectures are shared, with each discipline having its own tutorials. Hence, there is little opportunity for interprofessional learning.
⁎ Corresponding author. Tel.: +61 399044018; fax: +61 399044655. E-mail addresses: [email protected] (G. McLelland), [email protected] (L. McKenna), [email protected] (J. French). 1 Tel.: +61 39905492; fax: +61 39904837. 2 Tel.: +61 399044019; fax: +61 399044655.
In 2010, final year midwifery students at Monash University participated in the core unit ‘Education for Clinical Practice’. The unit covers a broad range of teaching, learning theories, types of teaching and learning in nursing and midwifery, planning, developing and evaluating teaching. An education unit was introduced for two reasons. Firstly, it sought to increase awareness of final year nursing and midwifery students of their roles of teachers in their prospective careers, and secondly assist them develop theory and skills to teach others from both, their own and other health professions. When midwifery students first took this unit, it had been in place for one year. Third year nursing students had successfully undertaken peer teaching for first year nursing students (McKenna and French, 2011). As part of the final assessment, the third year students taught temperature, pulse and respiration or blood pressure to students in a first year clinical nursing unit. Organising the teaching experiences requires careful coordination between the timetables of both cohorts.
0260-6917/$ – see front matter. Crown Copyright © 2012 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.10.016
G. McLelland et al. / Nurse Education Today 33 (2013) 724–728
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When considering the first group of midwifery students entering the unit in 2010, it was recognised that they would particularly benefit by building on their own basic, but specific, midwifery clinical skills. With further investigation, it was identified there was no area of alignment with the first and second year midwifery units. However it was known that there was a second year Bachelor of Emergency Health (Paramedic) (BEH) lifespan unit where undergraduate paramedic students learned about normal childbirth. Whilst the BEH students learned theory of normal childbirth, and were instructed upon the care of the mother and newborn, there were no practical sessions to facilitate development of clinical skills. This presented an opportunity to introduce an interprofessional peer teaching and learning event, enabling midwifery students to teach basic childbirth skills, while simultaneously allowing paramedic students to have some hands-on practice. The midwifery students were briefed about the lecture on normal childbirth delivered to the paramedic students so they could fully appreciate their foundational knowledge. In pairs, prior to the sessions, midwifery students prepared and developed lesson plans, including learning objectives, focussed on care given to mother and baby during and after, childbirth. The lesson plans were assessed by the lecturer who taught the childbirth session to the paramedics to ensure consistency with paramedics' knowledge and between midwifery students' groups. The lessons were delivered to paramedic students under direct supervision of midwifery lecturers, who also had education expertise.
other to enable effective collaboration and improve health outcomes” (p.13). While interprofessional education and peer teaching are both contemporary in health professional education, little evidence could be found of examples of them being used together. In a US study, Wilson et al. (2012) report on an interdisciplinary course designed to teach patient safety to six health professional groups. They used peer evaluation as one part of the evaluation around individual contribution to the group over the semester; however, they only report that peers rated each other highly.
Background
The Clinical Teaching Preference Questionnaire (CTPQ), developed by Iwasiw and Goldenberg (1993), was used in the previous evaluation of peer teaching in nursing, and considered a validated and applicable tool (McKenna and French, 2011). Since the first study, it has undergone further testing (Williams et al., in press). Hence, it was deemed appropriate with the undergraduate paramedic students. The tool consists of ten statements with five-point Likert scale ranging from strongly agree (1) to strongly disagree (5). The midwifery students evaluated their experiences with the adapted Peer Teaching Experience Questionnaire (PTEQ) that had been used in the original evaluation of the third year nursing students. This tool was adapted by McKenna and French (2011) from the original CTPQ. Slight adjustment of one question in each tool for use in this current study was “Teaching is an important role for midwives” and “Teaching is an important role for paramedics” rather than ‘nurses’ as in the original. In addition, both tools had two statements added relating to the interprofessional experience of the current study. Both cohorts were given the statement “Interprofessional teaching is an important role for health professionals”, while paramedic students were given “I enjoyed the interprofessional experience” and the midwifery students “There should be more opportunities for interprofessional teaching in the curriculum”. Demographic data sought on from both groups included: age, gender, prior tertiary study, experience either teaching or being taught by peers and any interprofessional teaching experience. An open ended section gave students an opportunity to comment further on their peer teaching/learning experience. Early in the semester, paramedic students were informed about the planned inter-professional activity including detail about different evaluations of the sessions. Four to six weeks after the sessions, but still within the same semester, paramedic and midwifery students respectively received the CTPQ or the PTEQ distributed by a lecturer not involved in the peer teaching exercise. While all students were invited to complete the questionnaire, participation in the research was voluntary, resulting in an overall response rate of 64.9% (n= 37) of midwifery students and 44.0% (n= 73) of paramedic students. In the following semester, both paramedic students and midwifery students were invited to participate in focus groups about the peer teaching/learning experience. Ten midwifery students participated in one focus group and five paramedics in the other. Quantitative data were analysed using Statistical Package for Social Sciences
Teaching is an important part of the midwife's role. Midwives teach women and their families across the childbearing continuum such as antenatal education for pregnancy, labour and birth, postnatal education in breastfeeding, baby and self-care. The Australian Nursing and Midwifery Council National Competency Standards for the Midwife (2006) clearly articulate these responsibilities through provision of ‘learning opportunities appropriate to the woman's needs’ (p. 7) and enhancing ‘the professional development of self and others’ (p.13). Hence, there is a need to ensure midwifery students have opportunities to develop knowledge and skills around provision of education. This includes being able to teach, not only women and their families, but other health professionals. Peer teaching or peer assisted learning has been present in the nursing literature since the 1970s, although only intermittently. Recently, however, there has been renewed interest in its potential value and application. Secomb (2007) conducted a systematic review of peer teaching in health professional clinical education, concluding that peer teaching increases student learning outcomes. In medicine, Gregory et al. (2011) conducted a study with third year medical students teaching ECG interpretation with second year students. Their findings indicate that preparing to teach, along with peer teaching, improves the learning of peer teachers and retention of that learning. In 1993, Iwasiw and Goldenberg evaluated peer teaching in undergraduate nursing in Canada. In doing so, they developed the Clinical Teaching Evaluation Questionnaire (CTEQ). In comparing two groups of students in the clinical area, one taught by instructors and the other by peers, they concluded that findings supported the use of peer teaching. In our team's prior study involving junior and senior nursing students, third year students reported increased self-confidence in their teaching capabilities and were able to see how they would use these skills in their graduate practice. First year students reported feeling more comfortable learning from other students, and learnt more broadly from the senior students (McKenna and French, 2011). Interprofessional education has also gained momentum in the health professions over recent years. The World Health Organization (2010) defines interprofessional education as that which “occurs when two or more professions learn about, from and with each
Aim of Research To explore the educational and professional benefits of using inter-professional Peer Assisted Learning (PAL) by undergraduate midwifery students teaching skills for undergraduate paramedic students. Ethics This research was an addition to another a larger project that also explored the benefits of PAL between senior and junior nursing students. Ethics was granted by the university's human ethics committee for both this and the original project. This research was conducted over two years, 2010 and 2011. Methods
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(SPSS v. 19) using descriptive statistics. Focus groups were audio recorded and transcribed. Qualitative data were analysed using a content analysis approach informed by Grbich (2007). Two of the researchers reviewed the transcripts in order to validate findings. Results Demographic Data The midwifery student cohort was all female and ages were widely distributed. Just over half (54%) were more than 30 years old. A little over half (54.1%) of midwifery students reported prior studies and while nearly one quarter (24.3%) had previously experienced peer teaching, very few (5.6%) had any interprofessional teaching experience. In the paramedic student cohort just over half (57.7%) were male. Overall, the paramedic cohort tended to be younger with a majority (89.7%) 30 years old or younger. Almost one half (49.4%) of all paramedic students reported experience with previous peer teaching and just under one fifth (17.9%) had prior interprofessional student learning experiences. Peer Teaching Experience Following the unit and their peer teaching sessions, the midwifery students were very enthusiastic about the inter-professional peer teaching experience. The overwhelming majority strongly believed that teaching is an important role for midwives (M=1.16; SD= 0.374) and that midwives have a professional responsibility to teach students and their peers (M= 1.35; SD =0.538) (Table 1). Overall they believed this was a very rewarding experience that would assist them as they made their transition to their graduate years (M = 1.57; SD = 0.502). As the majority had not been required to teach before, especially to another health professional, varying degrees of initial apprehension were reported (M = 2.16; SD = 1.167). However, mostly the midwifery students considered the unit was well worth the time and effort (M = 1.49; SD = 0.559) with the peer teaching experience being personally rewarding (M= 1.46; SD= 0.558). After the teaching sessions the midwifery students revealed they were comfortable teaching the paramedic students (M = 1.68; SD = 0.580) as they expressed their enjoyment about working with another discipline (M = 1.35; SD = 0.484) and they felt there should be more peer teaching in the curriculum (M= 1.97; SD= 0.833). Results further revealed they felt more confident with future teaching of a clinical skill (M= 1.73;
Table 1 Peer Teaching Experience Questionnaire (PTEQ) — midwifery students.
Teaching an important role for midwives What I have learnt in this unit will help with my graduate midwife role The peer teaching experience was time and effort well spent The peer teaching experience was personally rewarding I now understand the principles underpinning teaching and learning I was initially apprehensive about the peer teaching requirement in this unit I felt comfortable teaching the paramedic students I have developed skills for teaching basic clinical skills The peer teaching experience allowed me to reflect on my own previous experience I enjoyed working with the paramedic students I felt uncomfortable evaluating the paramedic students' skills I would be more confident teaching a clinical skill after this experience There should be more opportunities for peer teaching in the curriculum Midwives have a professional responsibility to teach students and their peers
N
Mean
SD
37 37
1.16 1.57
0.374 0.502
37 37 37
1.49 1.46 1.70
0.559 0.558 0.571
37
2.16
1.167
37 37 37
1.68 1.62 1.57
0.580 0.492 0.555
37 33 37
1.35 3.27 1.73
0.484 1.232 0.508
37
1.97
0.833
37
1.35
0.538
SD = 0.508) with the midwifery students feeling they had developed the skills to teach basic clinical skills (M= 1.62; SD= 0.492)due to the principles of teaching and learning (M= 1.70; SD = 0.571) they had learned. Qualitative findings supported, and added to, the statistical results with three key aspects revealed — “Not fair at first”; “Building confidence” and “Our Passion”. The first, “Not fair at first” reflected their feelings before and as they overcame their initial fears: “… we were all, this is not fair at the start…they get to do TPR … so simple in comparison to what we teach … wouldn't have changed it … invaluable…” (M.S. 2) “I think it was an amazing experience but at the first couple of lessons I thought how am I going to do this, this is ridiculous…” (M.S. 9) “I think earlier in the semester, I thought it was all a bit of crap….on reflection I can understand why we did it” (M.S. 5) The second key aspect, “Building confidence”, reflected the increased confidence with their own knowledge that midwifery students discovered because they had to teach others: “When you teach something, it makes you think about what you know because you can't teach something unless you know it” (M.S. 2) “We felt so good afterwards, so confident, like I really do know my stuff.” (M.S. 4) “Yeah, it validates what we've learned” (M.S. 5) The third key aspect, “Our passion”, tied the first two together as students expressed their great delight in being able to teach their passion to another discipline: “You actually see that with 12 or 18 months placement experience we don't necessarily think about what we're saying, it's just a part of what we do” (M.S. 6) “… we were able to show our passions…” (M.S. 3) “… we were able to advocate for midwives in general…” (M.S. 8) Learning From Peers While the paramedic students tended to be relatively positive about the peer learning experience, they were more ambivalent than the midwifery students. Like the midwifery students, the paramedic students believed that teaching was an important role for paramedics (M = 1.62; SD = 0.585) (Table 2) although slightly less than midwifery students. Findings revealed that the paramedic students were slightly less anxious (M = 2.40; SD = 0.972) with a reported increased interaction and collaboration (M = 2.12; SD = 0.837) when taught by the midwifery students. However, paramedic students were more neutral when rating their self-confidence with performing a skill independently and feedback they received from the midwifery students (M = 2.91; SD = 0.871). Interestingly, while they tended to be more neutral about the support they received from the midwifery students (M = 2.86; SD = 0.0.963), they also tended to be less able to approach their instructor (M = 3.08; SD = 0.937). The paramedic students revealed some apprehension about the midwifery students' lack of teaching. Overall they disclosed an increased sense of responsibility when taught by their instructor (M = 2.40; SD = 0.858) and they also indicated they felt they may learn more than from the instructor than their peers (M = 2.62; SD = 0.901). While suggesting the paramedic students needed to be reassured that they had instructor expertise supporting their learning, overall they valued the
G. McLelland et al. / Nurse Education Today 33 (2013) 724–728 Table 2 Clinical Teaching Preference Questionnaire (CTPQ) — paramedic students.
Teaching is an important role for paramedics I feel freer to approach my instructor Instructor teaching improves problem solving I am less anxious in the presence of my peers Interaction and collaboration is increased by being taught by other students Being taught clinical skills by my instructor increases my sense of responsibility I learn more from my instructors than my peers I can communicate more freely with my peers than my instructor The feedback from my peers is from a student's viewpoint, therefore more honest realistic and helpful than from my instructor My peers are more supportive to me when I am performing a clinical skill than my instructor I am more self confident and able to perform independently because of being taught by my peers more than my instructor
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Table 3 Interprofessional experience.
N
Mean
78 78 78 78 78
1.62 3.08 2.82 2.40 2.12
SD 0.586 0.937 0.908 0.972 0.837
Midwifery students Interprofessional teaching is an important role for health professionals There should be more opportunities for interprofessional teaching in the curriculum
78
2.40
0.858
78 78
2.62 3.55
0.901 10.978
Paramedic students Interprofessional teaching is an important role of health professionals I enjoyed the interprofessional experience
78
2.96
0.959
78
2.86
0.963
78
2.91
0.871
inter-professional peer learning highlighting the importance of a variety of learning approaches. Again, qualitative findings supported and added to the statistical data gathered. Two major key aspects were identified “They knew their stuff” and “It was valuable”. The first, “They knew their stuff”, recognised the unique knowledge of the midwifery students and acknowledges their teaching skills:
N
Mean
SD
37
1.43
0.502
37
1.78
0.672
78
1.86
0.639
78
1.59
0.612
Again, qualitative findings supported the quantitative statistics with the general theme “Inter-professional interactions”. In retrospect it may have been beneficial to ask both cohorts the same questions regarding the interprofessional experience (Table 3). Interestingly each cohort addressed these queries in the focus groups. The midwifery students were very enthusiastic about the interprofessional experience and the paramedic students felt there should be more interprofessional opportunities in the undergraduate curriculum especially with nurses. Both cohorts recognised that they were not isolated professions, and that interactions with other undergraduate health professions in shared education activities would be of benefit: “It's absolutely invaluable. It's the biggest learning tool. It was I think it was an amazing experience…” (M.S. 5)
“... The students … were prepared, they knew their stuff … and were really hands on…” (P.S. 1)
“... be more integrated with other disciplines because we're not an isolated part of the health system, we're going to have to interact with them…” (P.S. 4)
“... they've just learnt it, they know how to remember things and how they prioritized it and that's fresh for them” (P.S. 5)
“…greatest benefit would be with nurses… encouraging interaction at an early stage…” (P.S. 1)
“... they knew all the answers … was reassuring” (P.S. 3) “... I reckon the midwife [sic] students were great teachers…” (P.S. 1) In the second aspect, “It's valuable”, paramedic students valued the sessions and appreciated the “hands on” practical applications used: “I think it's [video] valuable, I didn't enjoy it but I think it was valuable” (P.S. 5) “The hands on [mannequin], you can't beat the hands on… it was just a real benefit doing it” (P.S. 3) “You could apply it to a visual concept [handouts] provided by the dummy in front of you…then follow the steps of procedures…” (P.S. 1) “… just worked really well in giving a positive environment in which to learn…” (P.S. 2)
Interprofessional Experience Overwhelmingly, both midwifery and paramedic students enjoyed and valued the inter-professional teaching/learning experience (Table 3). Both cohorts felt that interprofessional teaching is an important role for all health professionals, with midwifery students agreeing slightly more strongly than the paramedic students. Midwifery students agreed there should be more opportunities for interprofessional teaching in the curriculum. Both midwifery and paramedic students enjoyed the experience very much.
The midwifery students valued their own specific knowledge defining the uniqueness of their own discipline. They recognised that their profession is a specialist field focussing on specific knowledge, whereas other generalist professions, such as paramedicine, may not require the same depth of understanding: “It makes you not afraid to talk …to other disciplines and don't assume … they know more, …you can be completely confident with what you know” (M.S. 7) An unexpected outcome was an increased understanding of the other profession's role and the limits of each discipline's scope of practice, especially for the midwifery students: “I think everyone's general perception is that a paramedic will just know it all. You know, … they can't possibly…” (M.S. 4) Discussion Teaching is an important element in the roles of health professionals. However, few educational curricula contain content relevant to this area. At the authors' university, a formal core unit, that aims to bridge this deficit, has been successfully offered to nursing students since 2009 (McKenna and French, 2011). The findings of the current study suggest that this is equally as valuable for midwifery students. In addition, the current approach included teaching across discipline barriers. Midwifery students' ratings on the CTEQ aligned very similarly with those of nursing student teachers in McKenna and French's (2011) study, indicating that midwifery and nursing students share similar attributes in this area. The results suggest that peer teaching offered the midwifery students an opportunity to consolidate their own knowledge as well as increasing their confidence with the newer, but required, skill
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of teaching. However, it is unclear whether other senior health professional students would achieve value from the peer teaching to the same extent. With regard to the paramedic students and the PTEQ, there was also similarity between the paramedic and junior nursing students receiving the peer teaching, with one exception. Paramedic students were much less agreeable that ‘I can communicate more freely with my peers than my instructor’ (M= 3.55; SD = 10.98) than the junior nursing students (M= 2.089; SD= 0.99) as reported by McKenna and French (2011). This is possibly due to the interprofessional nature of the current experience and the perceived less knowledge about midwifery. While the results suggest that the junior learners valued the peer teaching, they also needed to be reassured from expert instructors. Overall the interprofessional learning exercise (IPLE) proved to be very successful with both student groups enjoying the sessions. Both cohorts of students were able to fulfil the learning outcomes required by their respective subjects and as an added bonus an increased awareness of the other professions scope of practice. The paramedic students recognised the unique expertise required by midwives when supporting birthing women. Midwifery students acknowledged that childbirth was a minor component of the overall workload for paramedics. While both cohorts of students expressed a new found respect and empathy for the other professions, each found their own professional identity was reinforced to some degree particularly the midwifery students. This finding supported other studies noting undergraduate IPLE increased understanding of the skills and roles of other professions (Illingworth and Chelvanayagam, 2007). However, like other reported undergraduate IPLE, several hurdles needed to be overcome. Most of the hurdles encountered were the associated time required to negotiate the of timetable conflicts encountered while organising the sessions supporting other IPLE research (Davidson et al., 2008; Cullen et al., 2003). Whilst the nursing and paramedic buildings are adjacent on the campus, the two undergraduate courses are managed by different departments so multiple timetable clashes required many hours ensuring implementation of the teaching sessions. Fortunately, the midwifery students' timetable could be adjusted to suit the paramedic students' scheduled laboratory times and there was sufficient time to plan this change. Other hurdles encountered also mostly related to time constraints as there was slight misunderstanding about the research process, particularly from the paramedic students in the initial year. These hurdles could have been overcome with adequate funding to support IPLE in undergraduate as encouraged by Learning and Teaching for Interprofessional Practice Australia (Dunston et al., 2009). The present study has built on those of previous work to support the importance of structured peer teaching experiences for students (Iwasiw and Goldenberg, 1993; McKenna and French, 2011; Secomb, 2007), and has explored this further in the context of interprofessional
education. The authors acknowledge that there are limitations to this study. It included students only from two disciplines and from one campus of an Australian university. Hence, they cannot be considered to be generalizable to other populations. It does, however, extend our understandings of this area. More research with peer teaching across other health professional groups is recommended. Conclusion Traditionally PAL occurs between students of the same discipline at different levels. However, this experience crossed professional boundaries through the implementation of teaching sessions between third year midwifery students and second year paramedic students. Both cohorts of students were able to successfully fulfil the learning objectives of their respective subjects. In addition, by crossing professional boundaries, a new mutual respect and greater understanding of the scope of practice for each discipline developed between the students. Whilst both PAL and IPLE can be logistically difficult to organise, this research highlights the benefits of using both in undergraduate curricula. References Australian Nursing and Midwifery Council, 2006. National Competency Standards for the Midwife. ANMC, Canberra. Cullen, L., Fraser, D., Symonds, I., 2003. Strategies for interprofessional education: the Interprofessional Team Objective Structured Clinical Examination for midwifery and medical students. Nurse Education Today 23, 427–433 http://dx.doi.org/ 10.1016/S0260-6917(03)00049-2. Davidson, M., Smith, R.A., Dodd, K.J., Smith, J.S., O'Loughlan, M.J., 2008. Interprofessional pre-qualification clinical education: a systematic review. Australian Health Review 32 (1), 111–120. Dunston, R., Lee, A., Lee, A., Matthews, L., Nisbet, G., Pockett, R., Thistlethwaite, J., White, J., 2009. Interprofessional Health Education in Australia: The Way Forward. University of Technology, Sydney and The University of Sydney, Sydney . (Retrieved August 29th 2012 http://www.rilc.uts.edu.au/pdfs/wayforward.pdf). Grbich, C., 2007. Qualitative Data Analysis: An Introduction. SAGE, Los Angeles. Gregory, A., Walker, I., McLaughlin, K., Peets, A.D., 2011. Both preparing to teach and teaching positively impact learning outcomes for peer teachers. Medical Teacher 33, e417–e422. Illingworth, P., Chelvanayagam, S., 2007. Benefits of interprofessional education in health care. British Journal of Nursing 16 (2), 121–124. Iwasiw, C.L., Goldenberg, D., 1993. Peer teaching among nursing students in the clinical area: effects on student learning. Journal of Advanced Nursing 18, 659–668. McKenna, L., French, J., 2011. A step ahead: teaching undergraduate students to be peer teachers. Nurse Education in Practice http://dx.doi.org/10.1016/j.nepr.2010.10.003. Secomb, J., 2007. A systematic review of peer teaching and learning in clinical education. Journal of Clinical Nursing 17, 703–716. Williams, B., McKenna, L., French, J., Dousek, S., in press. The Clinical Teaching Preference Questionnaire (CTPQ): an exploratory factor analysis. Nurse Education Today. Wilson, A.R., Fabri, P.J., Wolfson, J., 2012. Human error and patient safety: interdisciplinary course. Teaching and Learning in Medicine 24, 18–25. World Health Organization, 2010. Framework for Action on Interprofessional Education & Collaborative Practice. World Health Organization, Geneva.
Contents lists available at SciVerse ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Crossing professional barriers with peer-assisted learning: Undergraduate midwifery students teaching undergraduate paramedic students Gayle McLelland a,⁎, Lisa McKenna b, 1, Jill French c, 2 a b c
School of Nursing & Midwifery, Monash University, Peninsula Campus, Australia School of Nursing & Midwifery, Monash University, Clayton Campus, Australia School of Nursing & Midwifery, Monash University, Berwick Campus, Australia
a r t i c l e
i n f o
Article history: Received 7 September 2012 Received in revised form 16 October 2012 Accepted 24 October 2012 Keywords: Interprofessional Peer teaching Midwifery student Paramedic student PAL
s u m m a r y Background: Peer assisted learning (PAL) has been shown in undergraduate programmes to be as effective as learning from instructors. PAL is a shared experience between two learners often with one being more senior to the other but usually both are studying within the same discipline. Interprofessional education occurs when two or more professionals learn with, from and about each other. Benefits of PAL in an interprofessional context have not been previously explored. As part of a final year education unit, midwifery students at Monash University developed workshops for second year undergraduate paramedic students. The workshops focused on care required during and after the birth of the baby. Aim: To investigate the benefits of an interprofessional PAL for both midwifery and paramedic students. Methods: Data for this project were obtained by both quantitative and qualitative methods. Questionnaires were distributed to both cohorts of students to explore experiences of peer teaching and learning. Results were analysed using Statistical Package for Social Sciences (SPSS). Focus groups were conducted separately with both cohorts of students and transcripts analysed using a thematic approach. Findings: Response rates from the midwifery and paramedic students were 64.9% and 44.0% respectively. The majority of students regardless of discipline enjoyed the interprofessional activity and wanted more opportunities in their curricula. After initial anxieties about teaching into another discipline, 97.3 (n = 36) of midwifery students thought the experience was worthwhile and personally rewarding. Of the paramedic students, 76.9% (n = 60) reported enjoying the interaction. The focus groups supported and added to the quantitative findings. Both midwifery and paramedic students had a new-found respect and understanding for each other's disciplines. Midwifery students were unaware of the limited knowledge paramedics had around childbirth. Paramedic students admired the depth of knowledge displayed by the midwifery students. Implications: This study indicates both educational and professional benefits for undergraduate students from different disciplines having shared PAL activities. Crown Copyright © 2012 Published by Elsevier Ltd. All rights reserved.
Introduction At the Peninsula campus of Monash University, the nursing building is located directly adjacent to the paramedic building. Yet, there are very few interprofessional activities between the two areas. Students of both the Bachelor of Midwifery and Bachelor of Emergency Health degrees participate together in one science subject per semester in their first year, however only lectures are shared, with each discipline having its own tutorials. Hence, there is little opportunity for interprofessional learning.
⁎ Corresponding author. Tel.: +61 399044018; fax: +61 399044655. E-mail addresses: [email protected] (G. McLelland), [email protected] (L. McKenna), [email protected] (J. French). 1 Tel.: +61 39905492; fax: +61 39904837. 2 Tel.: +61 399044019; fax: +61 399044655.
In 2010, final year midwifery students at Monash University participated in the core unit ‘Education for Clinical Practice’. The unit covers a broad range of teaching, learning theories, types of teaching and learning in nursing and midwifery, planning, developing and evaluating teaching. An education unit was introduced for two reasons. Firstly, it sought to increase awareness of final year nursing and midwifery students of their roles of teachers in their prospective careers, and secondly assist them develop theory and skills to teach others from both, their own and other health professions. When midwifery students first took this unit, it had been in place for one year. Third year nursing students had successfully undertaken peer teaching for first year nursing students (McKenna and French, 2011). As part of the final assessment, the third year students taught temperature, pulse and respiration or blood pressure to students in a first year clinical nursing unit. Organising the teaching experiences requires careful coordination between the timetables of both cohorts.
0260-6917/$ – see front matter. Crown Copyright © 2012 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.10.016
G. McLelland et al. / Nurse Education Today 33 (2013) 724–728
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When considering the first group of midwifery students entering the unit in 2010, it was recognised that they would particularly benefit by building on their own basic, but specific, midwifery clinical skills. With further investigation, it was identified there was no area of alignment with the first and second year midwifery units. However it was known that there was a second year Bachelor of Emergency Health (Paramedic) (BEH) lifespan unit where undergraduate paramedic students learned about normal childbirth. Whilst the BEH students learned theory of normal childbirth, and were instructed upon the care of the mother and newborn, there were no practical sessions to facilitate development of clinical skills. This presented an opportunity to introduce an interprofessional peer teaching and learning event, enabling midwifery students to teach basic childbirth skills, while simultaneously allowing paramedic students to have some hands-on practice. The midwifery students were briefed about the lecture on normal childbirth delivered to the paramedic students so they could fully appreciate their foundational knowledge. In pairs, prior to the sessions, midwifery students prepared and developed lesson plans, including learning objectives, focussed on care given to mother and baby during and after, childbirth. The lesson plans were assessed by the lecturer who taught the childbirth session to the paramedics to ensure consistency with paramedics' knowledge and between midwifery students' groups. The lessons were delivered to paramedic students under direct supervision of midwifery lecturers, who also had education expertise.
other to enable effective collaboration and improve health outcomes” (p.13). While interprofessional education and peer teaching are both contemporary in health professional education, little evidence could be found of examples of them being used together. In a US study, Wilson et al. (2012) report on an interdisciplinary course designed to teach patient safety to six health professional groups. They used peer evaluation as one part of the evaluation around individual contribution to the group over the semester; however, they only report that peers rated each other highly.
Background
The Clinical Teaching Preference Questionnaire (CTPQ), developed by Iwasiw and Goldenberg (1993), was used in the previous evaluation of peer teaching in nursing, and considered a validated and applicable tool (McKenna and French, 2011). Since the first study, it has undergone further testing (Williams et al., in press). Hence, it was deemed appropriate with the undergraduate paramedic students. The tool consists of ten statements with five-point Likert scale ranging from strongly agree (1) to strongly disagree (5). The midwifery students evaluated their experiences with the adapted Peer Teaching Experience Questionnaire (PTEQ) that had been used in the original evaluation of the third year nursing students. This tool was adapted by McKenna and French (2011) from the original CTPQ. Slight adjustment of one question in each tool for use in this current study was “Teaching is an important role for midwives” and “Teaching is an important role for paramedics” rather than ‘nurses’ as in the original. In addition, both tools had two statements added relating to the interprofessional experience of the current study. Both cohorts were given the statement “Interprofessional teaching is an important role for health professionals”, while paramedic students were given “I enjoyed the interprofessional experience” and the midwifery students “There should be more opportunities for interprofessional teaching in the curriculum”. Demographic data sought on from both groups included: age, gender, prior tertiary study, experience either teaching or being taught by peers and any interprofessional teaching experience. An open ended section gave students an opportunity to comment further on their peer teaching/learning experience. Early in the semester, paramedic students were informed about the planned inter-professional activity including detail about different evaluations of the sessions. Four to six weeks after the sessions, but still within the same semester, paramedic and midwifery students respectively received the CTPQ or the PTEQ distributed by a lecturer not involved in the peer teaching exercise. While all students were invited to complete the questionnaire, participation in the research was voluntary, resulting in an overall response rate of 64.9% (n= 37) of midwifery students and 44.0% (n= 73) of paramedic students. In the following semester, both paramedic students and midwifery students were invited to participate in focus groups about the peer teaching/learning experience. Ten midwifery students participated in one focus group and five paramedics in the other. Quantitative data were analysed using Statistical Package for Social Sciences
Teaching is an important part of the midwife's role. Midwives teach women and their families across the childbearing continuum such as antenatal education for pregnancy, labour and birth, postnatal education in breastfeeding, baby and self-care. The Australian Nursing and Midwifery Council National Competency Standards for the Midwife (2006) clearly articulate these responsibilities through provision of ‘learning opportunities appropriate to the woman's needs’ (p. 7) and enhancing ‘the professional development of self and others’ (p.13). Hence, there is a need to ensure midwifery students have opportunities to develop knowledge and skills around provision of education. This includes being able to teach, not only women and their families, but other health professionals. Peer teaching or peer assisted learning has been present in the nursing literature since the 1970s, although only intermittently. Recently, however, there has been renewed interest in its potential value and application. Secomb (2007) conducted a systematic review of peer teaching in health professional clinical education, concluding that peer teaching increases student learning outcomes. In medicine, Gregory et al. (2011) conducted a study with third year medical students teaching ECG interpretation with second year students. Their findings indicate that preparing to teach, along with peer teaching, improves the learning of peer teachers and retention of that learning. In 1993, Iwasiw and Goldenberg evaluated peer teaching in undergraduate nursing in Canada. In doing so, they developed the Clinical Teaching Evaluation Questionnaire (CTEQ). In comparing two groups of students in the clinical area, one taught by instructors and the other by peers, they concluded that findings supported the use of peer teaching. In our team's prior study involving junior and senior nursing students, third year students reported increased self-confidence in their teaching capabilities and were able to see how they would use these skills in their graduate practice. First year students reported feeling more comfortable learning from other students, and learnt more broadly from the senior students (McKenna and French, 2011). Interprofessional education has also gained momentum in the health professions over recent years. The World Health Organization (2010) defines interprofessional education as that which “occurs when two or more professions learn about, from and with each
Aim of Research To explore the educational and professional benefits of using inter-professional Peer Assisted Learning (PAL) by undergraduate midwifery students teaching skills for undergraduate paramedic students. Ethics This research was an addition to another a larger project that also explored the benefits of PAL between senior and junior nursing students. Ethics was granted by the university's human ethics committee for both this and the original project. This research was conducted over two years, 2010 and 2011. Methods
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(SPSS v. 19) using descriptive statistics. Focus groups were audio recorded and transcribed. Qualitative data were analysed using a content analysis approach informed by Grbich (2007). Two of the researchers reviewed the transcripts in order to validate findings. Results Demographic Data The midwifery student cohort was all female and ages were widely distributed. Just over half (54%) were more than 30 years old. A little over half (54.1%) of midwifery students reported prior studies and while nearly one quarter (24.3%) had previously experienced peer teaching, very few (5.6%) had any interprofessional teaching experience. In the paramedic student cohort just over half (57.7%) were male. Overall, the paramedic cohort tended to be younger with a majority (89.7%) 30 years old or younger. Almost one half (49.4%) of all paramedic students reported experience with previous peer teaching and just under one fifth (17.9%) had prior interprofessional student learning experiences. Peer Teaching Experience Following the unit and their peer teaching sessions, the midwifery students were very enthusiastic about the inter-professional peer teaching experience. The overwhelming majority strongly believed that teaching is an important role for midwives (M=1.16; SD= 0.374) and that midwives have a professional responsibility to teach students and their peers (M= 1.35; SD =0.538) (Table 1). Overall they believed this was a very rewarding experience that would assist them as they made their transition to their graduate years (M = 1.57; SD = 0.502). As the majority had not been required to teach before, especially to another health professional, varying degrees of initial apprehension were reported (M = 2.16; SD = 1.167). However, mostly the midwifery students considered the unit was well worth the time and effort (M = 1.49; SD = 0.559) with the peer teaching experience being personally rewarding (M= 1.46; SD= 0.558). After the teaching sessions the midwifery students revealed they were comfortable teaching the paramedic students (M = 1.68; SD = 0.580) as they expressed their enjoyment about working with another discipline (M = 1.35; SD = 0.484) and they felt there should be more peer teaching in the curriculum (M= 1.97; SD= 0.833). Results further revealed they felt more confident with future teaching of a clinical skill (M= 1.73;
Table 1 Peer Teaching Experience Questionnaire (PTEQ) — midwifery students.
Teaching an important role for midwives What I have learnt in this unit will help with my graduate midwife role The peer teaching experience was time and effort well spent The peer teaching experience was personally rewarding I now understand the principles underpinning teaching and learning I was initially apprehensive about the peer teaching requirement in this unit I felt comfortable teaching the paramedic students I have developed skills for teaching basic clinical skills The peer teaching experience allowed me to reflect on my own previous experience I enjoyed working with the paramedic students I felt uncomfortable evaluating the paramedic students' skills I would be more confident teaching a clinical skill after this experience There should be more opportunities for peer teaching in the curriculum Midwives have a professional responsibility to teach students and their peers
N
Mean
SD
37 37
1.16 1.57
0.374 0.502
37 37 37
1.49 1.46 1.70
0.559 0.558 0.571
37
2.16
1.167
37 37 37
1.68 1.62 1.57
0.580 0.492 0.555
37 33 37
1.35 3.27 1.73
0.484 1.232 0.508
37
1.97
0.833
37
1.35
0.538
SD = 0.508) with the midwifery students feeling they had developed the skills to teach basic clinical skills (M= 1.62; SD= 0.492)due to the principles of teaching and learning (M= 1.70; SD = 0.571) they had learned. Qualitative findings supported, and added to, the statistical results with three key aspects revealed — “Not fair at first”; “Building confidence” and “Our Passion”. The first, “Not fair at first” reflected their feelings before and as they overcame their initial fears: “… we were all, this is not fair at the start…they get to do TPR … so simple in comparison to what we teach … wouldn't have changed it … invaluable…” (M.S. 2) “I think it was an amazing experience but at the first couple of lessons I thought how am I going to do this, this is ridiculous…” (M.S. 9) “I think earlier in the semester, I thought it was all a bit of crap….on reflection I can understand why we did it” (M.S. 5) The second key aspect, “Building confidence”, reflected the increased confidence with their own knowledge that midwifery students discovered because they had to teach others: “When you teach something, it makes you think about what you know because you can't teach something unless you know it” (M.S. 2) “We felt so good afterwards, so confident, like I really do know my stuff.” (M.S. 4) “Yeah, it validates what we've learned” (M.S. 5) The third key aspect, “Our passion”, tied the first two together as students expressed their great delight in being able to teach their passion to another discipline: “You actually see that with 12 or 18 months placement experience we don't necessarily think about what we're saying, it's just a part of what we do” (M.S. 6) “… we were able to show our passions…” (M.S. 3) “… we were able to advocate for midwives in general…” (M.S. 8) Learning From Peers While the paramedic students tended to be relatively positive about the peer learning experience, they were more ambivalent than the midwifery students. Like the midwifery students, the paramedic students believed that teaching was an important role for paramedics (M = 1.62; SD = 0.585) (Table 2) although slightly less than midwifery students. Findings revealed that the paramedic students were slightly less anxious (M = 2.40; SD = 0.972) with a reported increased interaction and collaboration (M = 2.12; SD = 0.837) when taught by the midwifery students. However, paramedic students were more neutral when rating their self-confidence with performing a skill independently and feedback they received from the midwifery students (M = 2.91; SD = 0.871). Interestingly, while they tended to be more neutral about the support they received from the midwifery students (M = 2.86; SD = 0.0.963), they also tended to be less able to approach their instructor (M = 3.08; SD = 0.937). The paramedic students revealed some apprehension about the midwifery students' lack of teaching. Overall they disclosed an increased sense of responsibility when taught by their instructor (M = 2.40; SD = 0.858) and they also indicated they felt they may learn more than from the instructor than their peers (M = 2.62; SD = 0.901). While suggesting the paramedic students needed to be reassured that they had instructor expertise supporting their learning, overall they valued the
G. McLelland et al. / Nurse Education Today 33 (2013) 724–728 Table 2 Clinical Teaching Preference Questionnaire (CTPQ) — paramedic students.
Teaching is an important role for paramedics I feel freer to approach my instructor Instructor teaching improves problem solving I am less anxious in the presence of my peers Interaction and collaboration is increased by being taught by other students Being taught clinical skills by my instructor increases my sense of responsibility I learn more from my instructors than my peers I can communicate more freely with my peers than my instructor The feedback from my peers is from a student's viewpoint, therefore more honest realistic and helpful than from my instructor My peers are more supportive to me when I am performing a clinical skill than my instructor I am more self confident and able to perform independently because of being taught by my peers more than my instructor
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Table 3 Interprofessional experience.
N
Mean
78 78 78 78 78
1.62 3.08 2.82 2.40 2.12
SD 0.586 0.937 0.908 0.972 0.837
Midwifery students Interprofessional teaching is an important role for health professionals There should be more opportunities for interprofessional teaching in the curriculum
78
2.40
0.858
78 78
2.62 3.55
0.901 10.978
Paramedic students Interprofessional teaching is an important role of health professionals I enjoyed the interprofessional experience
78
2.96
0.959
78
2.86
0.963
78
2.91
0.871
inter-professional peer learning highlighting the importance of a variety of learning approaches. Again, qualitative findings supported and added to the statistical data gathered. Two major key aspects were identified “They knew their stuff” and “It was valuable”. The first, “They knew their stuff”, recognised the unique knowledge of the midwifery students and acknowledges their teaching skills:
N
Mean
SD
37
1.43
0.502
37
1.78
0.672
78
1.86
0.639
78
1.59
0.612
Again, qualitative findings supported the quantitative statistics with the general theme “Inter-professional interactions”. In retrospect it may have been beneficial to ask both cohorts the same questions regarding the interprofessional experience (Table 3). Interestingly each cohort addressed these queries in the focus groups. The midwifery students were very enthusiastic about the interprofessional experience and the paramedic students felt there should be more interprofessional opportunities in the undergraduate curriculum especially with nurses. Both cohorts recognised that they were not isolated professions, and that interactions with other undergraduate health professions in shared education activities would be of benefit: “It's absolutely invaluable. It's the biggest learning tool. It was I think it was an amazing experience…” (M.S. 5)
“... The students … were prepared, they knew their stuff … and were really hands on…” (P.S. 1)
“... be more integrated with other disciplines because we're not an isolated part of the health system, we're going to have to interact with them…” (P.S. 4)
“... they've just learnt it, they know how to remember things and how they prioritized it and that's fresh for them” (P.S. 5)
“…greatest benefit would be with nurses… encouraging interaction at an early stage…” (P.S. 1)
“... they knew all the answers … was reassuring” (P.S. 3) “... I reckon the midwife [sic] students were great teachers…” (P.S. 1) In the second aspect, “It's valuable”, paramedic students valued the sessions and appreciated the “hands on” practical applications used: “I think it's [video] valuable, I didn't enjoy it but I think it was valuable” (P.S. 5) “The hands on [mannequin], you can't beat the hands on… it was just a real benefit doing it” (P.S. 3) “You could apply it to a visual concept [handouts] provided by the dummy in front of you…then follow the steps of procedures…” (P.S. 1) “… just worked really well in giving a positive environment in which to learn…” (P.S. 2)
Interprofessional Experience Overwhelmingly, both midwifery and paramedic students enjoyed and valued the inter-professional teaching/learning experience (Table 3). Both cohorts felt that interprofessional teaching is an important role for all health professionals, with midwifery students agreeing slightly more strongly than the paramedic students. Midwifery students agreed there should be more opportunities for interprofessional teaching in the curriculum. Both midwifery and paramedic students enjoyed the experience very much.
The midwifery students valued their own specific knowledge defining the uniqueness of their own discipline. They recognised that their profession is a specialist field focussing on specific knowledge, whereas other generalist professions, such as paramedicine, may not require the same depth of understanding: “It makes you not afraid to talk …to other disciplines and don't assume … they know more, …you can be completely confident with what you know” (M.S. 7) An unexpected outcome was an increased understanding of the other profession's role and the limits of each discipline's scope of practice, especially for the midwifery students: “I think everyone's general perception is that a paramedic will just know it all. You know, … they can't possibly…” (M.S. 4) Discussion Teaching is an important element in the roles of health professionals. However, few educational curricula contain content relevant to this area. At the authors' university, a formal core unit, that aims to bridge this deficit, has been successfully offered to nursing students since 2009 (McKenna and French, 2011). The findings of the current study suggest that this is equally as valuable for midwifery students. In addition, the current approach included teaching across discipline barriers. Midwifery students' ratings on the CTEQ aligned very similarly with those of nursing student teachers in McKenna and French's (2011) study, indicating that midwifery and nursing students share similar attributes in this area. The results suggest that peer teaching offered the midwifery students an opportunity to consolidate their own knowledge as well as increasing their confidence with the newer, but required, skill
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of teaching. However, it is unclear whether other senior health professional students would achieve value from the peer teaching to the same extent. With regard to the paramedic students and the PTEQ, there was also similarity between the paramedic and junior nursing students receiving the peer teaching, with one exception. Paramedic students were much less agreeable that ‘I can communicate more freely with my peers than my instructor’ (M= 3.55; SD = 10.98) than the junior nursing students (M= 2.089; SD= 0.99) as reported by McKenna and French (2011). This is possibly due to the interprofessional nature of the current experience and the perceived less knowledge about midwifery. While the results suggest that the junior learners valued the peer teaching, they also needed to be reassured from expert instructors. Overall the interprofessional learning exercise (IPLE) proved to be very successful with both student groups enjoying the sessions. Both cohorts of students were able to fulfil the learning outcomes required by their respective subjects and as an added bonus an increased awareness of the other professions scope of practice. The paramedic students recognised the unique expertise required by midwives when supporting birthing women. Midwifery students acknowledged that childbirth was a minor component of the overall workload for paramedics. While both cohorts of students expressed a new found respect and empathy for the other professions, each found their own professional identity was reinforced to some degree particularly the midwifery students. This finding supported other studies noting undergraduate IPLE increased understanding of the skills and roles of other professions (Illingworth and Chelvanayagam, 2007). However, like other reported undergraduate IPLE, several hurdles needed to be overcome. Most of the hurdles encountered were the associated time required to negotiate the of timetable conflicts encountered while organising the sessions supporting other IPLE research (Davidson et al., 2008; Cullen et al., 2003). Whilst the nursing and paramedic buildings are adjacent on the campus, the two undergraduate courses are managed by different departments so multiple timetable clashes required many hours ensuring implementation of the teaching sessions. Fortunately, the midwifery students' timetable could be adjusted to suit the paramedic students' scheduled laboratory times and there was sufficient time to plan this change. Other hurdles encountered also mostly related to time constraints as there was slight misunderstanding about the research process, particularly from the paramedic students in the initial year. These hurdles could have been overcome with adequate funding to support IPLE in undergraduate as encouraged by Learning and Teaching for Interprofessional Practice Australia (Dunston et al., 2009). The present study has built on those of previous work to support the importance of structured peer teaching experiences for students (Iwasiw and Goldenberg, 1993; McKenna and French, 2011; Secomb, 2007), and has explored this further in the context of interprofessional
education. The authors acknowledge that there are limitations to this study. It included students only from two disciplines and from one campus of an Australian university. Hence, they cannot be considered to be generalizable to other populations. It does, however, extend our understandings of this area. More research with peer teaching across other health professional groups is recommended. Conclusion Traditionally PAL occurs between students of the same discipline at different levels. However, this experience crossed professional boundaries through the implementation of teaching sessions between third year midwifery students and second year paramedic students. Both cohorts of students were able to successfully fulfil the learning objectives of their respective subjects. In addition, by crossing professional boundaries, a new mutual respect and greater understanding of the scope of practice for each discipline developed between the students. Whilst both PAL and IPLE can be logistically difficult to organise, this research highlights the benefits of using both in undergraduate curricula. References Australian Nursing and Midwifery Council, 2006. National Competency Standards for the Midwife. ANMC, Canberra. Cullen, L., Fraser, D., Symonds, I., 2003. Strategies for interprofessional education: the Interprofessional Team Objective Structured Clinical Examination for midwifery and medical students. Nurse Education Today 23, 427–433 http://dx.doi.org/ 10.1016/S0260-6917(03)00049-2. Davidson, M., Smith, R.A., Dodd, K.J., Smith, J.S., O'Loughlan, M.J., 2008. Interprofessional pre-qualification clinical education: a systematic review. Australian Health Review 32 (1), 111–120. Dunston, R., Lee, A., Lee, A., Matthews, L., Nisbet, G., Pockett, R., Thistlethwaite, J., White, J., 2009. Interprofessional Health Education in Australia: The Way Forward. University of Technology, Sydney and The University of Sydney, Sydney . (Retrieved August 29th 2012 http://www.rilc.uts.edu.au/pdfs/wayforward.pdf). Grbich, C., 2007. Qualitative Data Analysis: An Introduction. SAGE, Los Angeles. Gregory, A., Walker, I., McLaughlin, K., Peets, A.D., 2011. Both preparing to teach and teaching positively impact learning outcomes for peer teachers. Medical Teacher 33, e417–e422. Illingworth, P., Chelvanayagam, S., 2007. Benefits of interprofessional education in health care. British Journal of Nursing 16 (2), 121–124. Iwasiw, C.L., Goldenberg, D., 1993. Peer teaching among nursing students in the clinical area: effects on student learning. Journal of Advanced Nursing 18, 659–668. McKenna, L., French, J., 2011. A step ahead: teaching undergraduate students to be peer teachers. Nurse Education in Practice http://dx.doi.org/10.1016/j.nepr.2010.10.003. Secomb, J., 2007. A systematic review of peer teaching and learning in clinical education. Journal of Clinical Nursing 17, 703–716. Williams, B., McKenna, L., French, J., Dousek, S., in press. The Clinical Teaching Preference Questionnaire (CTPQ): an exploratory factor analysis. Nurse Education Today. Wilson, A.R., Fabri, P.J., Wolfson, J., 2012. Human error and patient safety: interdisciplinary course. Teaching and Learning in Medicine 24, 18–25. World Health Organization, 2010. Framework for Action on Interprofessional Education & Collaborative Practice. World Health Organization, Geneva.