Introduction
Graduate-level OT education requires students to integrate complex theoretical knowledge with professional reasoning and apply these concepts across diverse practice contexts (Araujo et al., 2022; Hooper & Wood, 2019). This process is cognitively demanding and often presents challenges related to knowledge integration, confidence, and effective learning strategies (Roberts & Simon, 2021). As students transition from foundational coursework to applied professional reasoning, they must demonstrate higher-level problem-solving and the ability to translate theory into practice (Hooper & Wood, 2019; Unsworth, 2017). These demands highlight the need for structured academic support beyond traditional classroom instruction and tutoring that promote engagement, application, and competency skills development (Burgess et al., 2020; Zhang & Maconochie, 2022).
Peer Assisted Learning (PAL) has emerged as an effective educational approach across health professions, supporting active, collaborative learning (Burgess et al., 2020; Feng et al., 2024; Yu et al., 2018). PAL involves structured, peer-led activities mentored by faculty and promotes deeper learning through dialogue, shared problem-solving, and application of knowledge (Burgess et al., 2020; Feng et al., 2024; Yu et al., 2018). Evidence suggests that PAL improves academic performance, engagement, critical thinking, and learner confidence while reducing anxiety in high stakes learning environments (Burgess et al., 2020; Feng et al., 2024; Tai et al., 2016; Yu et al., 2018). It also provides reciprocal benefits for peer educators, the PAL mentors, including reinforcement of knowledge and development of communication and leadership skills (Burgess et al., 2020; Feng et al., 2024; Zhang & Maconochie, 2022).
Despite this evidence, limited research has examined PAL within graduate OT education, particularly in relation to professional reasoning and preparation for practical examinations. To address this gap, this study evaluated a structured, faculty-supported PAL program implemented at a private health sciences university. The program focused on peer-led workshops designed to support application of coursework, development of professional reasoning, and preparation for practical and theoretical assessments.
Methods
Study Design
The study design was informed by best practices in health professions education and implemented as a structured, faculty-supported, peer-led intervention (Burgess et al., 2020; Feng et al., 2024; Yu et al., 2018). A mixed-methods approach without a control group was used to evaluate the impact of the PAL program on OT students’ academic performance, confidence, and learning strategies (Creswell & Plano Clark, 2018; Feng et al., 2024). Trained student mentors facilitated collaborative learning sessions focused on application of course content, clinical reasoning, and examination preparation. Data were collected using practical exam performance outcomes, pre- and post-intervention surveys, an adapted MSLQ (Pintrich et al., 1991), and qualitative feedback from a focus group.
Sample
Participants were first-trimester graduate occupational therapy students enrolled in master’s and doctoral programs at the university. They were taking foundational didactic courses, including Basic Patient Care Skills and Evaluation and Screening. Participation in the Peer-Assisted Learning (PAL) program was voluntary and was offered to students enrolled in these selected courses across two 15-week academic terms. A total of 56 out of 115 students participated in the study, 39 students completed pre-intervention surveys, 32 completed post-intervention surveys, 48 students’ practical exam scores were analyzed, and all 56 participants completed the adapted MSLQ. A subset of participants (n = 7) also participated in a focus group. Demographic information indicated that the sample was representative of the program’s typical student population, consisting of 43 female participants (77%) and 13 male participants (23%). Recruitment occurred through campus announcements, Canvas LMS postings, and communication from PAL coordinators, faculty, and class representatives.
Procedures
The PAL program was delivered across two 15-week-long academic terms through approximately eight structured, peer-led workshops aligned with course objectives and faculty-developed materials. Sessions were typically one hour in duration, with some extending beyond scheduled times based on student participation and instructional needs. Workshops were facilitated by trained peer mentors who demonstrated academic success and faculty approval. The typical ratio of PAL mentors to students was approximately 1:4 to support individualized guidance, active participation, and effective learning experiences. Sessions were conducted in person or virtually and incorporated active learning strategies, including case-based discussions, collaborative problem-solving, application of theoretical concepts, content review, and hands-on competency practice. Attendance was tracked to monitor participation. Participants completed pre- and post- intervention surveys administered electronically through Google Forms to assess baseline perceptions and post-intervention experiences. Qualitative data were collected through open-ended survey responses and a voluntary focus group conducted via videoconferencing.
Measures
Program outcomes were assessed using academic performance indicators and self-report instruments. Academic performance was evaluated through practical examination scores collected at multiple time points, including midterm and final practical assessments. One course included three practical examinations administered throughout the academic term, whereas the other course included two practical examinations. Practical exam performance was used to evaluate application of knowledge and professional reasoning.
An adapted version of the MSLQ was used to evaluate motivation and learning strategies, including self-efficacy, task value, metacognitive regulation, effort regulation, and help-seeking behaviors (Duncan & McKeachie, 2005; Pintrich et al., 1991; Segura-Robles et al., 2021). Qualitative data were collected through thematic analysis of adapted MSLQ and a semi-structured focus group exploring participants’ perceptions of PAL and its impact on learning, confidence, and application of course content.
Data Collection and Analysis
Quantitative data were analyzed using descriptive statistics, repeated-measures ANOVA, and paired-samples t-tests to examine changes in academic performance, confidence, and learning strategies following PAL participation. Practical exam outcomes were reviewed to identify trends in performance.
Qualitative data from survey responses and focus group transcripts were analyzed using thematic analysis following a systematic process of coding, category development, and theme identification (Castleberry & Nolen, 2018; Nowell et al., 2017). An audit trail was maintained to support rigor and transparency, and MAXQDA software was used to facilitate data organization and coding. Data were coded systematically to identify patterns and themes related to participants’ experiences, perceived benefits, and application of learning.
Findings from both data sources were integrated to provide a comprehensive understanding of the program’s effectiveness.
Results
Quantitative Findings
Practical examination scores were analyzed separately for the two courses due to differences in the number of practical assessments administered within the trimester. For the course with three practical examinations, repeated measures ANOVA demonstrated a statistically significant difference in scores across assessments. For the course with two practical examinations, paired-samples t-test results indicated improved scores between assessments. However, the difference was not statistically significant (see Table 1).
Participants reported consistently high perceptions of PAL effectiveness, motivation, and learning strategy use across post-intervention survey measures and adapted MSLQ constructs (see Tables 2 and 3). Students endorsed improvements in clinical reasoning, study strategies, application of PAL content to coursework, and confidence/preparation. Adapted MSLQ findings similarly demonstrated high levels of intrinsic value, task value, self-efficacy, metacognitive self-regulation, and effort regulation, suggesting strong engagement in reflective and application-based learning. Overall, findings indicate that participants perceived PAL as beneficial for supporting confidence, collaborative learning, and application of knowledge to practice.
Qualitative Findings
Qualitative findings complemented the quantitative survey results, including findings from the adapted MSLQ. A total of 56 participants completed the adapted MSLQ, and a subset of these participants (n = 7) additionally participated in the focus group. Focus group participants described experiences that aligned with the quantitative findings related to learning strategies, confidence, collaboration, and application of knowledge. Thematic analysis identified several recurring themes associated with participants’ experiences in the PAL program. Representative participant quotes and thematic interpretations are summarized in Table 4.
Collectively, qualitative findings suggest that participants perceived PAL as a supportive and collaborative learning approach that enhanced confidence, application of knowledge, and engagement in active learning and study strategies.
Discussion
This study examined the impact of a structured PAL program on graduate OT students’ academic performance, motivation, and learning strategies. Findings from both quantitative and qualitative analyses indicate that PAL participation was associated with increased confidence, improved application of knowledge, and adoption of effective study strategies. Although statistical findings for academic performance were mixed, the overall pattern supports PAL as a meaningful supplemental learning approach in graduate OT education.
Quantitative analyses demonstrated variability in academic outcomes across courses. While statistically significant improvements in practical exam performance were observed in one course, others did not reach significance. These differences may reflect variation in course structure, assessment design, and increasing complexity of skill expectations. High baseline performance likely contributed to limited measurable change, as many students maintained strong academic standing, including consistent high-level performance. These findings suggest that the impact of PAL may be reflected in the maintenance of strong performance rather than measurable gains alone.
Survey findings further support this interpretation. Students reported high perceived effectiveness across domains both pre- and post-intervention, suggesting sustained expectations related to clinical reasoning, knowledge application, and exam preparation. This pattern may indicate a ceiling effect, limiting observable change in self-report measures.
Findings from the adapted MSLQ indicated high intrinsic and task value, suggesting that students perceived PAL as engaging and relevant to application-based learning and self-regulated learning processes (Cook & Skrupky, 2025; Jansen et al., 2019). Elevated self-efficacy, along with strong metacognitive and effort regulation, indicates that PAL supported active, reflective learning. Although help-seeking behaviors were lower, students reported greater reliance on peer collaboration than mentor-directed support.
Other qualitative findings reinforced these results and aligned with previous PAL literature emphasizing collaborative learning, peer modeling, and confidence building (Burgess et al., 2020; Tai et al., 2016). Students described improvements in study strategies, understanding of course content, and confidence. The collaborative nature of PAL was identified as a key factor supporting active learning, peer modeling, and application of knowledge. These findings highlight the role of PAL in fostering a supportive learning environment that promotes both skill development and confidence.
Overall, findings suggest that PAL primarily impacts learning processes rather than performance outcomes alone. While exam score changes were variable, students demonstrated sustained high performance alongside improvements in confidence, engagement, and strategy use, supporting the role of PAL in developing professional reasoning.
Conclusions
PAL represents a valuable supplemental teaching and learning resource in graduate OT education. Although its impact on academic outcomes may vary, it consistently supports engagement, confidence, and application of knowledge. Importantly, students maintained high academic performance despite increasing exam complexity, suggesting that PAL contributes to performance stability as clinical demands advance.
Limitations and Future Research
This study has several limitations. The sample was relatively small and drawn from a single institution, limiting generalizability. Survey data were self-reported and subject to response bias. Variability in PAL attendance and differences in assessment structure across courses may have influenced outcomes.
Despite these limitations, findings suggest that PAL supports overall student learning, confidence, and professional development. Participation appears to facilitate professional reasoning, communication, and application of knowledge, supporting its use as a supplement to traditional instruction.
Future research should examine the long-term impact of PAL on academic performance and clinical competence and identify optimal implementation strategies across settings. Larger, multi-site studies with more controlled designs are needed to further evaluate effectiveness and scalability. Additional research should also explore the impact of the PAL mentor role on mentors’ learning, including its influence on professional reasoning, confidence, and long-term skill integration.