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Nurse Education in Practice 11 (2011) 141e145

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

A step ahead: Teaching undergraduate students to be peer teachers

Lisa McKenna a,*, Jill French b,1

aAssociate Professor, School of Nursing & Midwifery, Monash University, Clayton campus, Clayton Victoria 3800, Australiab Lecturer, School of Nursing & Midwifery, Monash University, Peninsula campus, Frankston Victoria 3199, Australia

a r t i c l e i n f o

Article history:Accepted 10 October 2010

Keywords:Focus groupsNursing studentPeer teachingQuestionnaire

* Corresponding author. Tel.: þ61 3 9905 3492; faxE-mail addresses: lisa.mckenna@monash.edu (L. M

edu (J. French).1 Tel.: þ61 3 9904 4019; fax: þ61 3 9904 4655.

1471-5953/$ e see front matter Crown Copyright � 2doi:10.1016/j.nepr.2010.10.003

a b s t r a c t

Nurses have a responsibility to share knowledge with others. However, many are reluctant to undertaketeaching, feeling unprepared for the responsibility. With this in mind, a semester-long compulsory coreunit was designed and implemented in 2009 to equip final year students with knowledge and skills toenable facilitation of teaching and learning in practice. As part of the summative assessment, third (final)year students taught vital signs in first year skills laboratories. To evaluate the strategy, the Peer TeachingExperience Questionnaire (adapted from Iwasiw and Goldenberg, 1993) was administered to third yearstudents and Clinical Teaching Preference Questionnaire (Iwasiw and Goldenberg, 1993) to first years.Focus groups were conducted with third year volunteers to explore issues in greater detail.

One hundred and five (75%) third year and 112 (52%) first year students completed questionnaires. Inaddition, 11 third year students participated in a focus group. Overall, third year students reportedincreased confidence in their knowledge and teaching abilities, reflected on their own learning andfound the experience rewarding, acquiring skills they considered would be helpful in graduate years.Many suggested there should be more opportunities for such types of learning and interaction. First yearstudents reported feeling comfortable learning skills with senior peers, as well as being able to learnfrom their experiences. Overall, both groups recognised strongly that teaching was part of nurses’ roles.

Crown Copyright � 2010 Published by Elsevier Ltd. All rights reserved.

Introduction

The unit ‘Education for Clinical Practice’ has been developed atMonash University to assist students to develop skills and heightentheir awareness of the role of nurses as teachers for students andother health professionals. Run for the first time in 2009, thecompulsory, core unit is offered over one academic semester in thefinal year of the undergraduate course. It covers a range of teachingand learning theories, types of teaching and learning in nursing,planning, developing and evaluating teaching. As part of theassessment for the unit, students are required deliver skills-basedlaboratory teaching to between one and three first year studentsunder direct supervision of lecturers. At the Peninsula campus, thechosen skills were temperature, pulse and respiration, or bloodpressure measurement. These were chosen by lecturers as theywere considered skills that final year students would haveconsolidated, and teaching of these in the first year unit coincidedwith the timing for teaching in the final year program. In prepa-ration for their sessions, students were required to develop

: þ61 3 9905 4837. .cKenna), jill.french@monash.

010 Published by Elsevier Ltd. All

teaching plans that included learning objectives to allow them tofully appreciate, and be able to plan and deliver, effective teachingand learning processes as set in unit learning objectives. At the endof semester, final year students re-entered the clinical laboratory toundertake clinical assessments of these skills to close the educationloop.

Background

Peer teaching uses an approach where students are involved inthe teaching of other students and has been intermittentlydescribed in nursing education literature over many years. Theconcept of peer teaching in nursing is not new but it has receivedlittle attention over recent years, appearing to have faded from thefavour of academics. However, while there has been a decline innurse education, there has been a growth in this approach ineducation across other disciplines such as teacher education, aswell as a range of health sciences.

Peer-assisted learning

The concept of peer learning has been described by Boud (2001)as “a two-way, reciprocal learning activity” (p.3). Boud argues thatthis should “involve the sharing of knowledge, ideas and

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L. McKenna, J. French / Nurse Education in Practice 11 (2011) 141e145142

experience” (p.3) in amanner that is of benefit to both parties. Peer-assisted learning has become particularly prominent in medicaleducation over recent years, however, it has been argued that it isunder researched (Secomb, 2007) and reported (Ten Cate andDurning, 2007). Ross and Cumming (2005) broadly describe thisapproach as “any situationwhere people learn from, or with, othersof a similar level of training, background or other shared charac-teristic.” (p.113). These authors suggest many benefits exist to thisapproach, including reinforcement and revision of learning,provision of feedback, promotion of responsibility, increased self-confidence, role modelling, developing teaching, communication,appraisal, organisational and team working skills (Ross andCumming, 2005). In one example of its application, Nestel andKidd (2005) used peer-assisted learning with third year medicalstudents to develop first year students’ communication skills inpatient-centred interviews. These authors evaluated the benefits ofthis approach for the student tutors, finding through subjectivedata that students primarily developed greater awareness of theirskills in facilitating learning, important for effective patientteaching. In their studywith first and second yearmedical students,Lockspeiser et al. (2008) concluded that peer teaching opportuni-ties were valued by junior students as they provided access tolearners who had recent experience in learning the relevantmaterial, and senior students understood issues they were dealingwith.

It has been recognised that peer learning can be both formal andinformal in nature (Topping, 2005). Roberts (2010) asserts thatstudents learn from the experiences of their peers, referring to theconcept of vicarious learning, whereby listening and reflecting onthe experience of others leads to learning. In relation to theirclinical learning, students also learn survival skills and ‘unwrittenrules’ from their peers (Roberts, 2008) through their owncommunity in which only other students understand issues andhave the potential to help (Roberts, 2009). Senior peers can providejunior students with emotional support and reassurance ina context that allows for asking questions and expressing uncer-tainty (Christianson and Bell, 2010).

Peer teaching in nursing

In the late 1970s and 1980s, a number of authors described theapplication of peer teaching in nursing as an approach to teachingclinical skills (Burnside, 1971; Costello, 1989). Iwasiw andGoldenberg (1993) evaluated the use of peer teaching in a bacca-laureate nursing course using a Clinical Teaching PreferenceQuestionnaire (CTPQ). These authors used student peers to super-vise others at the same level performing surgical dressing. Theauthors found a significant increase in students’ skill level whenthey were peer taught. Students acting as peer teachers had moreopportunities for modelling behaviours and were found to rein-force their own previous learning.

Recently, studies around peer teaching and learning haveresurfaced in the nursing literature using different types ofapproaches. Loke and Chow (2007) used peer tutoring with smallnumbers of third and second year students in a maternity and childcare unit, as an adjunct to regular, scheduled classes. The qualitativefindings revealed the experience enhanced reflection and onlearning, critical thinking and cooperative learning for both groups,as well as personal and social benefits. However, the authors sug-gested that mismatches between teachers and learners may beproblematic.

Kurtz et al. (2010) used an approach requiring students todeliver a small laboratory presentation to two or three peers fol-lowed by a skills demonstration to the class. Students felt the

experience assisted to prepare them to teach, develop their rolesand increased confidence in their skills.

Other studies have described the application of peer teachingand learning in clinical practice settings. In one study, Bos (1998)used junior students to provide peer leadership for a small groupof students in clinical placements. Findings suggested that theopportunity allowed students to enhance their patient care pri-oritisation, critical thinking and clinical skills. Sprengel and Job(2004) paired senior and junior students entering their first clin-ical placement, settings that have been known to be anxiety-producing for new nursing students (Admi, 1997; Cooke, 1996).Their findings revealed mutual benefits such as reduced anxietyand increased self-confidence for the novice, and enhanced confi-dence for the senior student. Similarly, Christianson and Bell (2010)developed peer learning partnerships whereby third year studentsprovided learning support for first years in clinical practice. Juniorstudents reported feeling less isolated and better able to cope withchallenges arising, while senior students demonstrated enhancedreflection on, and confidence in, their practice.

It has been suggested that peer teaching and learning offersa range of potential benefits for nursing and midwifery education.In the clinical laboratory, skills are often taught by one or twoacademic staff with a group of up to 30 students. Within class timeconstraints, it may be difficult to guide and supervise all students’skills practice. Utilising peer teachers in these learning situations,students learning new skills can be closely guided and supervisedthrough their skills practice with a potential for better preparationon entering clinical placements in health care settings with livepatients.

Teaching has been identified by the Australian Nursing andMidwifery Council (2008) as a core competency for registerednurses. However, few educational programs offer students oppor-tunities to learn and develop their skills to be effective facilitators oflearning. Providing students with opportunities to teach othersmay promote a sense of the importance of facilitating learning formore junior nurses, encouraging a professional culture thatpromotes the development of upcoming, future registered nurses.

The study

This study sought to evaluate the effectiveness of peer teachingexperiences in the unit Education for Clinical Practice from theperspectives of both junior and senior students.

Methods

The Clinical Teaching Preference Questionnaire (CTPQ) (Iwasiwand Goldenberg, 1993) was identified as a validated and appli-cable tool by which to collect data for evaluating the peer learningand teaching exercise. The tool, which collects perspectives on peerteaching experiences, was used for first year students. This toolconsists of ten statements with five-point Likert scale ranging fromstrongly agree (1) to strongly disagree (5). No suitable existing toolfor evaluating the experience of the peer teachers (third yearstudents) could be located, so it was decided to adapt Iwasiw andGoldenberg, (1993) existing tool. The adapted tool was titled thePeer Teaching Experience Questionnaire (PTEQ). One commonstatement was added to both questionnaires, that being: ‘Teachingis an important role for nurses’. Demographic data also sought inboth questionnaires included: age, gender, prior tertiary study, andexperience either teaching peers or being taught by peers. Finally,an open-ended sectionwas provided to allow students to elaborateon their peer teaching/learning experience if they chose.

Prior to collecting data, ethical approval to undertake the projectwas obtained from the relevant university human ethics

Table 2Clinical Teaching Preference Questionnaire (CTPQ) - Year One students.

N Mean S. D.

Teaching is an important role for nurses 111 1.4144 .51290

L. McKenna, J. French / Nurse Education in Practice 11 (2011) 141e145 143

committee. Following the delivery of the peer learning andteaching experiences, both groups of students were separatelydebriefed about their experiences by one of their own lecturers insmall groups and with other students at their own level. Sessionsinvited general explorations of experiences, perceptions on peerteaching, and analysis of any critical incidents arising. On comple-tion of the debriefing session, students were provided with infor-mation about the evaluation questionnaire. As this constituteda research project, completion of the questionnaire was voluntary.All students were invited to complete the relevant questionnaire,resulting in responses from 105 (75%) third year and 112 (52%) firstyear students. In addition, third year students were invited toparticipate in a focus group to explore their peer teaching experi-ences in greater detail. Eleven students chose to participate in this.Quantitative data were analysed using SPSS (Statistical Package forthe Social Sciences) using descriptive statistics. Qualitative datafrom questionnaires and focus group were analysed using contentanalysis.

Results

Demographic data

In the year three cohort, 91.4% (n ¼ 96) were female. Ages werewidely distributed, although under 25 years accounted for 62.9%(n ¼ 66) of participants. Thirty (28.6%) reported having experiencebeing taught by peers. Seventy three (69.5%) reported no priorexperience teaching peers. Among the year one cohort, 88.5%(n ¼ 100) were female. Overall, the cohort was younger with 70.8%(n ¼ 80) being in the 17e21 year age range. Forty one (36.6%)reported having previously been taught by peers.

Peer teaching experience

After the unit and their peer teaching experience, the third yearstudents strongly believed teaching to be an important role fornurses (Table 1). Overall, they rated the experience highly, report-ing perceived benefits for their graduate practice, sense of personal

Table 1Peer Teaching Experience Questionnaire (PTEQ) - Year Three students.

N Mean S. D.

Teaching is an important role for nurses 105 1.2381 .42796What I have learnt in this unit will help with

my graduate nurse role105 1.6333 .61342

The peer teaching experience was timeand effort well spent

105 1.5238 .52064

The peer teaching experience waspersonally rewarding

105 1.5619 .55338

I now understand the principlesunderpinning teaching and learning

105 1.7286 .54167

I was initially apprehensive about thepeer teaching requirement in the unit

105 2.2762 1.02371

I felt comfortable teaching the junior students 105 1.9667 .88868I have developed skills for

teaching basic clinical skills105 1.6476 .49963

The peer teaching experience allowed meto reflect on my own previous learning

104 1.5769 .56932

I enjoyed working with the junior students 105 1.5143 .57369I felt uncomfortable assessing the

junior students’ skills105 3.3000 1.30384

I would be more confident teachinga clinical skill after this experience

105 1.6762 .56322

There should be more opportunitiesor peer teaching in the curriculum

105 1.8190 .80600

Nurses have a professional responsibilityto teach students and their peers

105 1.4429 .50628

Adapted from Iwasiw and Goldenberg (1993).

reward, and development of knowledge and skills in teaching andlearning. Findings suggest differing levels of initial apprehensionacross the cohort. This was expected asmany students had not beeninvolved in teaching others before.

Qualitative findings supported the statistical findings, with verypositive comments being received. Content analysis revealed thatthe experience prompted students to reflect on their own learning,for example:

It is AMAZING howmuch teaching someone can help you reflect onyour own knowledge and learning. This class was extremely beneficial.I have always HATED the idea of teaching ANYTHING TO ANY-ONE.but now I feel at least I have some of the basic skills needed toprovide education. (Year Three student #29).

Found this unit a very useful tool & encouraged me to reflect on myown teaching methods as well identifying my own learning. Moreopportunities to do peer to peer teaching would be beneficial. (YearThree student #51).

In addition, students recognised potential personal benefitsarising from the experience:

I feel this experience will have helped for future nursing both asa learner and as an educator. (Year Three student #10).

Prior to the teaching session, I was extremely nervous, however,afterwards I felt a sense of achievement & confidence. The skills I learntI will take with me when I am out in the workforce. (Year Threestudent #60).

Learning from peers

After the unit and their experience of learning from their seniorpeers, the first year students also believed teaching to be animportant role for nurses (Table 2), although this was less than forthe third years. Overall, these students were more neutral in their

I feel freer to approach my instructorfor help than I do my peers

112 2.7768 .90752

My ability to problem solve improvesmore from instructor teachingthan from my peers

112 2.5982 .88491

I am less anxious when performing anursing skill in the presence of mypeers than my instructor

112 2.0402 1.06994

Being taught clinical skills by my peersincreases my interaction andcollaboration with other studentsmore than when being taughtby my instructor

111 1.9640 .89369

Being taught clinical skills by myinstructor increases my sense ofresponsibility more than by beingtaught by my peers

112 2.4821 .93945

I learn more from my instructor than my peers 112 2.4732 1.05660I can communicate more freely

with my peers than with my instructor112 2.0893 .99144

The feedback I receive from my peersis from a student’s viewpoint, therefore,more honest, reliable, helpful thanfrom my instructor

112 2.6786 1.04161

My peers are more supportive to mewhen I am performing a nursingskill than my instructor

112 2.6473 1.07937

I am more self-confident and ableto perform independently becauseof being taught by my peers,more so than by my instructor

112 2.6429 1.06422

Adapted from Iwasiw and Goldenberg (1993).

L. McKenna, J. French / Nurse Education in Practice 11 (2011) 141e145144

responses regarding their experiences, with most responses justa small skew towards positive perspectives. Findings indicate thattheywere less anxious performing a skill in front of their peers thanlecturers, could communicate more freely thanwith their lecturers,and had more interaction with other students.

Qualitative responses from the first year studentswere generallypositive. However, some students highlighted in this section of thequestionnaire that there was unexpected variation in what indi-vidual peer teachers were teaching, as reflected in the following:

Some peer teachers were better than others. Sometimes it was feltthat one group would be disadvantaged by their peer teacher becauseof teaching methods/knowledge. (Year One student #82)

The third years made us feel very comfortable and gave us tipsthey’ve picked up over the years. However, not all third years gave thesame information, resulting in a knowledge gap between 1st years.(Year One student #113)

Other comments reflected senior students’ abilities to offera level of understanding that lecturers could not, and provideinteraction that is not normally afforded in a more relaxed learningenvironment, such as:

Peers were wonderful. They have been through it all before andunderstood & our feelings and desires to be confident & competent.GREAT program. (Year One student #88).

I liked the peer teaching, and felt more comfortable performingskills in front of them as a 1st year student. They did a good job andknow what they are talking about. It was good fun and it was nice tomeet some of the 3rd years.(Year One student #80).

Great chance to work independently in small groups with anexperienced peer rather than watching an instructor with 20 þ otherpeople! (Year One student #48).

The environment was more relaxing and less stressful.(Year Onestudent #73).

Feedback suggested that peer learning was not only related tothe formal skill being covered. Discussion within the focus groupwith final year students indicated that first year students askedquestions about senior students’ prior experiences. In particular,not having been on clinical placement by that time, junior studentsasked many questions about what these were like.

Theyaskeda lot aboutour placements and theyaskeda lot aboutourown experiences especially when they found out that some of us werealready working as enrolled nurses. I guess that was a really good extraside learning to have real peer learning because as much as you havesomeone tell youwhat its like, its different coming from someonewho isdoing it while you’re doing it too.(Year Three student, focus group).

Discussion

This study has highlighted a range of potential benefits that canevolve from peer teaching and learning experiences in under-graduate nursing education. It sought to evaluate students’ expe-riences of peer teaching and learning within the first offering of thecore education unit. The findings suggest that this is was a mutuallypositive experience. For final year students, it presented a numberof particular benefits, including enhanced sense of achievementand confidence in their knowledge and skill level, similar to thefindings of Loke and Chow (2007). Further to that study, the currentstudy added quantitative evidence in addition to qualitative.Students reported the experience prompted them to reflect on theirown learning over their courses, and on their own practice. In linewith the study by Kurtz et al. (2010), it also heightened theirappreciation of the teaching role of nurses and provided themwithskills, knowledge and experience on which to begin to build thisaspect of their practice. These students indicated that the experi-encewould assist them in their graduate roles and felt strongly thatthere should be other opportunities for peer teaching and learning.

For the junior students, the experience presented positiveaspects but they were more neutral in their responses. This may, inpart, have been due to the fact that they were only a fewweeks intotheir first semester of the course. Many were still coming to termswith university, teaching methods and their chosen course. Theydid, however, recognise that teaching was a part of the nurse’s role.Having peer teachers available in the laboratory meant they wereable to report greater interaction and collaboration, rather thanwaiting for a busy lecturer to get to them. Similar to findings fromother studies (Sprengel and Job, 2004), the first year students didreport feeling less anxious when practising their skills in front oftheir peer teacher than a lecturer, and less inhibited communica-tion with their instructor. Some first year students did reportdiscrepancies between what different peer teachers had presentedand such discrepancies had not been anticipated. However, it isunclear whether this was due to mismatch in learning styles asLoke and Chow (2007) found. It is difficult to ensure that peerteachers have the requisite knowledge to effectively deliver theirsessions. Such issues require careful consideration in the planningand preparation of peer teachers for their roles and have beenaddressed for subsequent offerings of our unit through recappingthe theoretical content underpinning the skill to be taught.

Despite the exercise involving formalised skills teaching, therewas also evidence from the final year students’ focus group thatinformal peer learning also occurred. This vicarious learning, in linewith Roberts’ (2010) work, was particularly around clinical place-ments. At the time of the teaching session, junior students had notundertaken any placements and had many questions and fears thatthe final year students were able to address. Supervising lecturersalso commented on the degree of informal learning taking place,recognising this as a valuable outcome of the experience. Thestructure of the course offers little other opportunity for students ofdifferent year levels to interact so this offered an additional, unin-tended benefit to the overall experience.

There are limitations to this study that need to be acknowl-edged. The study incorporated students from one campus at oneuniversity in Australia. Data collected was self-reported by the twogroups of students. Hence, caution should be taken in generalisingthe findings. Findings suggest that there are benefits to seniorstudents engaging in peer teaching experiences with juniorstudents. However, further research is needed to extend ourunderstandings of its advantages and disadvantages. Research isneeded to evaluate the long-term effects of teaching undergraduatestudents to teach and the benefits to clinical practice, includingwhether this impacts upon teaching and learning support forothers in these areas. In addition, evaluating the impact on overalllearning and clinical preparation for junior students resulting fromsenior peer teachers in clinical laboratories would be beneficial.

Conclusions

Teaching is a recognised part of the nurse’s role. However, fewcurricula currently facilitate development of knowledge and skillsdevelopment in this area. Imbedding peer teaching opportunitiesoffers a means for achieving this, both formally and informally. Itenhances development of self-confidence and reflective practicefor peer teachers, and can reduce anxiety and enhance practiceopportunities for peer learners.

References

Admi, H., 1997. Nursing students’ stress during the initial clinical experience.Journal of Nursing Education 36 (7), 323e327.

Australian Nursing and Midwifery Council, 2008. National Competency Standardsfor the Registered Nurse. ANMC, Canberra.

L. McKenna, J. French / Nurse Education in Practice 11 (2011) 141e145 145

Bos, S., 1998. Perceived benefits of peer leadership as described by junior bacca-laureate nursing students. Journal of Nursing Education 37 (4), 189e191.

Boud, D., 2001. Introduction: Making the move to peer learning. In: Boud, D.,Cohen, R., Sampson, J. (Eds.), Peer Learning in Higher Education: Learning fromand with Each Other. Kogan Page, London.

Burnside, I., 1971. Peer supervision: a method of teaching. Journal of NursingEducation 10 (3), 15e22.

Christianson, A., Bell, A., 2010. Peer learning partnerships: Exploring the experienceof pre-registration nursing students. Journal of Clinical Nursing 19, 803e810.

Cooke, M., 1996. Nursing students’ perceptions of difficult or challenging clinicalsituations. Journal of Advanced Nursing 24 (6), 1281e1287.

Costello, J., 1989. Learning from each other: peer teaching and learning in studentnurse training. Nurse Education Today 9, 203e206.

Iwasiw, C.L., Goldenberg, D.,1993. Peer teaching amongnursing students in the clinicalarea: effects on student learning. Journal of Advanced Nursing 18, 659e668.

Kurtz, C.P., Lemley, C.S., Alverson, E.M., 2010. The master student presenter: peerteaching in the simulation laboratory. Nursing Education Perspectives 31 (1),38e40.

Lockspeiser, T.M., O’’Sullivan, P., Teherani, A., Muller, J., 2008. Understanding theexperience of being taught by peers: the value of social and cognitivecongruence. Advances in Health Sciences Education 13, 361e372.

Loke, A.J.T., Chow, F.L.W., 2007. Learning partnership e the experience of peertutoring among nursing students: a qualitative study. International Journal ofNursing Studies 44, 237e244.

Nestel, D., Kidd, J., 2005. Peer assisted learning in patient-centred interviewing: theimpact on student tutors. Medical Teacher 27 (5), 439e444.

Roberts, D., 2008. Learning in clinical practice: the importance of peers. NursingStandard 23 (12), 35e41.

Roberts, D., 2009. Friendship fosters learning: the importance of friendships inclinical practice. Nurse Education in Practice 9, 367e371.

Roberts, D., 2010. Vicarious learning: a review of the literature. Nurse Education inPractice 10, 13e16.

Ross, M.T., Cumming, A.D., 2005. In: Dent, J.A., Harden, R.M. (Eds.), Peer-assistedlearning.

Secomb, J., 2007. A systematic review of peer teaching and learning in clinicaleducation. Journal of Clinical Nursing 17, 703e716.

Sprengel, A.D., Job, L., 2004. Reducing student anxiety by using clinical peer men-toring with beginning nursing students. Nurse Educator 29 (6), 246e250.

Ten Cate, O., Durning, S., 2007. Peer teaching in medical education: Twelve reasonsto move theory to practice. Medical Teacher 29, 591e599.

Topping, K.J., 2005. Trends in peer learning. Educational Psychology 25 (6),631e645.