review article the value of peer learning in undergraduate...

Hindawi Publishing CorporationISRN NursingVolume 2013, Article ID 930901, 10 pageshttp://dx.doi.org/10.1155/2013/930901

Review ArticleThe Value of Peer Learning in Undergraduate NursingEducation: A Systematic Review

Robyn Stone, Simon Cooper, and Robyn Cant

Monash University, School of Nursing and Midwifery, Berwick Campus, 100 Clyde Road, Berwick 3806, Australia

Correspondence should be addressed to Robyn Stone; [email protected]

Received 23 December 2012; Accepted 9 February 2013

Academic Editors: L. H. Beebe and M. M. Funnell

Copyright © 2013 Robyn Stone et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The study examined various methods of peer learning and their effectiveness in undergraduate nursing education. Using a specifi-cally developed search strategy, healthcare databases were systematically searched for peer-reviewed articles, with studies involvingpeer learning and students in undergraduate general nursing courses (in both clinical and theoretical settings) being included.Thestudies were published in English between 2001 and 2010. Both study selection and quality analysis were undertaken independentlyby two researchers using published guidelines and data was thematically analyzed to answer the research questions. Eighteen studiescomprising various research methods were included. The variety of terms used for peer learning and variations between studydesigns and assessment measures affected the reliability of the study. The outcome measures showing improvement in either anobjective effect or subjective assessmentwere considered a positive result with sixteen studies demonstrating positive aspects to peerlearning including increased confidence, competence, and a decrease in anxiety.We conclude that peer learning is a rapidly develop-ing aspect of nursing education which has been shown to develop students’ skills in communication, critical thinking, and self-con-fidence. Peer learning was shown to be as effective as the conventional classroom lecturemethod in teaching undergraduate nursingstudents.

1. Introduction

Nursing education studies have often focused on traditionalteaching methods such as classroom lecture learning, a be-haviourism-based teachingmethod based onpassive learning[1]. More effective student-centric learning methods are nowbeing utilized to encourage active student participation andcreative thinking [2–4]. One of these methods is peer learn-ing, in which peers learn from one another, involving activestudent participation and where the student takes responsi-bility for their learning. Despite being used for many years,one of the barriers to advancement of peer learning is alack of consistency in its definition [5]. It is known by dif-ferent interchangeable titles such as “cooperative learning,”“mentoring,” “peer review learning,” “peer coaching,” “peermentoring,” “problem-based learning,” and “team learning.”

Peer learning has been used in education to addresscritical thinking, psychomotor skills, cognitive development,clinical skills, and academic gains [6–9]. One type of peer

learning is problem-based learning (PBL) which is character-ized by students learning from each other and from indepen-dently sourced information [10]. It is student centered, utiliz-ing group work with the analysis of case studies as a meansof learning. Alternatively “peer tutoring” involves individualsfrom similar settings helping others to learn, which mayoccur one-on-one or as small group sessions [11]. In nursing,high student numbers increase pressures [12] whilst variedand innovative teachingmethods are beneficial [13] with peerlearning offering a strategy that may be advantageous.

The Oxford Dictionary (2009) defines a “peer” as some-one of the same age or someone who was attending the sameuniversity. The term “peer” can also refer to people who haveequivalent skills or a commonality of experiences [14]. Boththese definitions suit the concept of peer learning describedhere. The current study aimed to address the followingresearch questions: (i) do undergraduate nursing studentsbenefit from peer learning? and (ii) what approaches to peerlearning are the most effective?

2 ISRN Nursing

2. Methods

Operational terms as shown in Table 1 were developed afterconsulting several studies. Inclusion and exclusion criteriawere defined. A search was conducted for peer-reviewedpapers published in English between the years 2000 and 2010that discussed any aspect of the curriculum for undergradu-ate or general nursing courses (e.g., clinical skills, communi-cation, patient interaction, or theoretical knowledge).

The literature searchwas undertaken using the PICOalgo-rithm of Participant, Intervention, Comparison, and Out-come and guidelines fromThe Cochrane Handbook [15]. Forthis study the following terms were used:

participant—undergraduate nursing students,

intervention—peer learning,

comparison—classroom lecture learning,

outcome—improvement in theory results or results ofpractical assessment or personal feelings relating tocomfort, confidence, or competence.

A systematic literature search of multiple databases andsearch engines was undertaken using the keywords and thesearch strategy described in the following.Thekeywords usedwere student nurse, undergraduate nurse, peer learning, peertutoring, peer mentoring, education, and opinion leaders.Also used were variations and truncations of these words,for example, peer education, nurse education, and problem-based learning. Each of the key words was searched forindividually and then in combination with all others.

In addition, a number of key nursing journals such asJournal of Advanced Nursing and Journal of Nursing Edu-cation were hand-searched between the years 2000 and 2010.Snowballing, identifying suitable articles from the referencesof the selected studies, was then conducted to locate furtherstudies.

Studies with all levels of evidence that met the criteriawere included because studies in peer learning tendedtowards quasiexperimental, observational, or case studydesigns which are all lower on the hierarchy of evidence [16].

Two reviewers conducted a quality analysis of each studyusing quality criteria for qualitative and quantitative studiesof the Critical Skills Appraisal Programme (CASP) [17].They assessed methodology, validity, sample type, selectionmethod, level of evidence, and any attrition rate and its effect(including biases), to determine selection. Consensus wasreached through discussion. Data extraction and thematicanalysis were undertaken to synthesize the data. Meta-analysiswas not undertaken due to the inconsistent definitionof “peer” and potential for bias if different methods of peerlearning were combined. Although the primary review wasconducted by a single researcher, inclusion and exclusion cri-teria were adhered to, using a transparent reporting processto allow the search to be reproduced.

Data were extracted and summarized in separate tables:quantitative studies (Table 2), qualitative studies (Table 3),and mixed method studies (Table 4). Drawing from this,data outcomes were collated into themes and subthemes; for

Table 1: Operational definitions.

Term Definition

Peer

A person with a comparable or slightly higherlevel of knowledge and experience to the learner.A person of any age can be a peer, that is, a thirdyear student tutoring a first year student but thepeer must be an undergraduate nursing student.

Peer learning Gaining, refining, or improving knowledge frominteraction with a peer as defined previously.

Mentor A peer, who supports, guides, and educates alearner.

Undergraduatenursing student

A nursing student at any stage of study prior toregistration.

Sources: [10, 14, 45, 48–51].

FilterExclude papers not meeting the

criteria after reading the title and

Selection of articles49 papers assessed by both

reviewers

Exclusion of nonnursing, postgraduate

learning, or continuing education articles

Exclude peer/mentor not as defined, books, reports, and

editorials. Assess quality and methodology

Review

18 papers included in systematic review

Literature searchPeer learning in undergraduate nursing in multiple databases

abstract (𝑛 = 1768)

Figure 1: Flow chart of the systematic review selection process.

example, the resources theme had three subthemes: faculty,students, and peers.

3. Results

Initially, 1813 studies were screened using the aforementionedcriteria and 18 studies were selected for review. A flow chart(Figure 1) shows the selection process including number ofstudies excluded at each stage and the reason for exclusion.

3.1. Characteristics of Studies. Participants were undergradu-ate nursing students from first to final year. In line with nurs-ing demography the majority of participants were females.Participant numbers and study duration varied, for example,15 students over a three-year period [18] and 365 students overa two-year period [7]. A variety of peer learning terms andmethods were used. These terms included “peer mentor-ing” [19], “peer tutoring” [7, 20–23], “peer coaching” [24],“inquiry-based learning” [25, 26], “problem-based learning”[27–31], and “team learning” [32].

Of these studies, eight used a qualitative method, sixutilized a quantitative method, and four usedmixedmethods

ISRN Nursing 3

Table 2: Summary of included studies.

Author Design Intervention andcomparison Country and setting

Broscious and Saunders(2001) [24]

Mixed methodGroup interview and questionnaire Peer coaching Junior and senior year students: Christopher

Newport University in USAChristiansen and Bell(2010) [19]

QualitativeInterpretive Peer learning UK University preregistration nursing

courseChristiansen and Jensen(2008) [33]

QualitativeEthnographic Role playing Third year student nurses in Norway

Cooke and Moyle (2002)[27] Qualitative—case studies PBL versus CLL Second year students at university in

Australia

Daley et al. (2008) [20]Qualitative

Observation, focus groups, andjournaling

Peer tutoring Ohio State University, College of NursingStudents

Feingold et al. (2008)[32]

Mixed methodsObservation and interviews Team learning First year student nurses: university in South

Western USA

Goldsmith et al. (2006)[7]

Mixed methodPortfolios, clinical assessment, and

questionnairesPeer learning First/third year students: Clinical Practice

Unit (CPU) of a nursing school in Australia

Higgins (2004) [21] QuantitativeQuasiexperimental

Peer tutoring versusnonpeer tutored

Medical-surgical undergraduate nursingcourse: Texas, USA

Hughes et al. (2003) [35] QuantitativePretest/posttest crossover

Peer group experienceversus nonpeer group

experienceBaccalaureate school of nursing in USA

Horne et al. (2007) [25]Qualitative

Focus group interviews and use offourth generation evaluation

Enquiry-based learning Second year students at a higher educationsetting in the UK

Lin et al. (2010) [22] QuantitativeExperimental

Peer tutoring. PBL methodin class versus CLL Nursing ethics classes: university in Taiwan

Loke and Chow (2007)[23]

QualitativeFocus groups and individual

interviewsCooperative learning Second/third year student nurses: university

in Hong Kong

Morris and Turnbull(2004) [26]

Qualitative evaluationFocus group interviews, field notes Peer tutoring 3-year undergraduate nursing course in the

UK

Ozturk et al. (2008) [28] QualitativeDescriptive, analytical PBL versus CLL Fourth year undergraduate student nurses

from two universities in Izmir, Turkey

Rideout et al. (2002) [29] Quantitative surveyCross-sectional analytical design PBL versus CLL Baccalaureate school of nursing and CLL

programme in Canada

Roberts (2008) [18] QualitativeInterpretive ethnographic Informal peer learning

Undergraduate students over a three-yearcourse in a range of acute settings includingintensive care, general surgical,rehabilitation, and medical wards in the UK

Siu et al. (2005) [30]Quantitative

Descriptive, correlation surveydesign

PBL versus CLL Two universities in Ontario, Canada

Tiwari et al. (2006) [31] Mixed methodsRandom controlled trial and survey PBL versus CLL First year student nurses: university in Hong

KongPBL: problem-based learning, CLL: classroom lecture learning.

(see Table 2). The quantitative studies favoured scaling andrating approaches (e.g., Likert scales), applying valid toolsincluding the Californian Critical Thinking DispositionInventory [28, 31], the Psychological Empowerment Scale[30], or the Nursing Ethical Discrimination Ability Scale [22]to collect data. The qualitative studies used a variety of col-lection methods such as participant observation [18], focusgroups [19, 20, 25, 26, 33], individual interviews [23], andopen ended short answer questions [27]. Combinations of

these methods were used by the mixed method studies. Inaddition a variety of statistics software and applicable inferen-tial statistics were used in the quantitative andmixedmethodstudies, whilst the qualitative studies used applicable thematicapproaches to analysis.

The analysis tools and tests used were presented (seeTables 1, 2, 3, 4, and 5) and considered as part of the qualityanalysis. Whilst quantitative studies give a definitive, mea-surable result, the use of qualitative studies in this paper

4 ISRN Nursing

Table3:Quantitativ

estudies.

Author/year

Aim

sSample/metho

dPo

wer

calcula-

tion/softw

are/analysistool

used

Outcomes

Generalizationand

confou

ndingfactors

Furtherresearch

Higgins

(200

4)[21]

Todeterm

iner

elationship

betweenacadem

icperfo

rmance,retentio

n,andparticipationin

apeer-tu

torin

gprogramme.

Purposives

ample:26

at-risk

studentsw

ere

offered

peer

tutorin

g𝑛=20peer

tutored;

𝑛=6in

nonp

eer

tutoredgrou

p

(i)Po

wer

calculationno

tgiven.

(ii)F

isher’sexacttest;atwo

bytwobivaria

tefre

quency

distr

ibution.

Sign

ificant

relationshipbetween

academ

icperfo

rmance/retentio

nand

participationin

apeer-tutorin

gprogramme.Attrition

rate

decreasedfro

m12%to

3%.

Diffi

cultto

generalize—

norand

omization;

thosew

hosoug

htpeer

tutorin

gmay

bemorem

otivated

topass.Small

samplelim

itedthefi

nding.

Other

nursingprograms

shou

lddu

plicatep

eer

tutorin

gfora

t-risk

studentsintheirc

ourses

Hug

hese

tal.

(2003)

[35]

Toinvestigatee

ffectof

aninform

alpeer

grou

pexperie

nceo

nbaccalaureaten

ursin

gstu

dents.

Con

venience

sampling

Voluntaryselection

𝑁=128

Insufficientp

ower

todetect

grou

pdifferences;m

ultip

letoolsa

ssessed,anxiety,

depressio

n,professio

nal

socialization,

andgeneral

self-effi

cacy.

Nosig

nificantd

ifferences

betweengrou

ps,but

increased

depressio

n(m

ean0.83,SD0.55)

andanxiety(m

ean2.40

,SD

0.81).

Restric

tedto

twoun

iversities.

Not

generalized.A

necdotal

accoun

ts:programmew

asbeneficialm

aintaining

contact

with

othersfro

mgrou

p,assis

tingcoping

skills.

Needforlon

gitudinal

study

onnu

rsingat

varyingsta

gesincourse

Linetal.

(2010)

[22]

Tocompare

thee

ducatio

nal

results

ofpeer

tutor

prob

lem-based

learning

andconventio

nalteaching

innu

rsingethics

education.

Con

venience

sampling

Rand

omlyassig

nedto

controland

interventio

ngrou

pscontrol=

70,

interventio

n=72

Nopo

wer

calculationdo

ne.

Nursin

gEthical

Disc

riminationAb

ility

Scale;Learning

Satisfaction

Survey.Internalcon

sistency

reached0.8andsplit-halves

reliabilitywas

0.76.

Both

metho

dseffectiv

efor

teaching

ethics

with

PBL

(𝑃<0.01)slightlymore

effectiv

ethanconventio

nal

lecture(𝑃=0.020).

Onlyon

euniversity.Lim

ited

training

ofpeers,no

evaluatio

nof

howpeersd

idtheirjob.Teaching

materials/teachersmay

have

influ

encedresult.

Stud

ents

used

toCL

Lmay

prefer

this.

Metho

dneedsfurther

valid

ation.

Ozturketal.

(2008)

[28]

Tocompare

effectsof

PBL

andtradition

aleducation

onsenior

undergradu

ate

nursingstu

dents’critical

thinking

disposition

s.

Con

venience

sampling:

PBL=52,C

LL=95

Power

calculationno

tgiven.

CaliforniaC

ritical

Thinking

Disp

osition

Inventory.Independ

ent

t-tests

forb

etween-grou

pdifferences.

PBLgrou

pshow

edhigh

erlevels

ofcriticalthink

ingthan

control

grou

p(𝑃<0.01);bo

thgrou

psin

medium

rangefor

critical

thinking

(between240and300

onCC

TDI).

Twoun

iversities,voluntary

participation,

butgoo

drespon

serates.Generalization

couldbe

madew

ithreservations

ascorrob

orate

previous

studies.

Allu

dedto

developm

ent

ofatoo

ltomeasure

criticalthink

ingthatis

mores

pecific

tonu

rsing.

Rideou

tetal.(2002)

[29]

Tocompare

graduate

baccalaureates

tudentsina

PBLcurriculum

with

others

inaC

LLprogramme.

Con

venience

sampling:

PBL=75,C

LL=52

Nopo

wercalculationgiven.

𝑃<0.01.t-te

sts,A

NOVA

forstatistic

alanalysis.

Nodifferences

infin

alexam

results

(𝑃=0.21)P

assed:PB

L93%andCL

L98%)

Restric

tedto

twoun

iversities.

Future

studies

tobe

long

itudinalindesig

nandrelyinglesson

self-repo

rtmeasures.

Siuetal.

(2005)

[30]

Toevaluateifnu

rsing

studentse

nrolledin

PBL

programmeh

adhigh

erperceptio

nsof

empo

wermentthanthose

inconventio

nallearning

lecture(CL

L).

Con

venience

sampling:

PBL=83,C

LL=70

Nopo

wercalculationgiven.

Con

ditio

nsforL

earning

Effectiv

enessQ

uestion

naire

(CLE

Q).Psycho

logical

Empo

wermentS

cale,

Teaching

-Learning

Strategies

Question

naire

,ClinicalProb

lem-Solving

Scale.ANCO

VA;

Spearm

an’sRh

oapplied.

PBLexperie

nced

greater

structuralem

powerment

(𝑃=0.001).Stud

entstaking

respon

sibilityfortheirow

nlearning

helped

develop

effectiv

ecom

mun

ication,

listening

,problem

solving,and

collabo

ratio

nskills.

Samplefrom

onlytwo

universities.Self-selectionand

self-repo

rtingqu

estio

nnaires

werea

potentialproblem

.

Needforlon

gitudinal

investigationand

replicationwith

samples

from

severaln

ursin

gprograms.

ISRN Nursing 5

Table4:Qualitatives

tudies.

Author/year

Aim

sParticipantsele

ction

Assessmentm

easures

Outcomes

Suggestedresearch

Chris

tiansen

andBe

ll(2010)

[19]

Toexploreimpactof

peer

learning

initiativetofacilitate

mutually

supp

ortiv

elearning

betweenstu

dent

nurses.

Purposively

selected.

𝑁=54.

Focusg

roup

interviews.

Narrativ

edatea

nalyzed

them

atically.

Datac

ollected

over

18mon

thsw

ith3

coho

rtso

fstudents.

Activ

esup

portfro

mpeersc

anredu

cenegativ

efeelin

gsexperie

nced

byfirstyear

student

nurses.Itassistsc

oping

anddecreasesa

ttrition

rates.Peersb

enefitedby

gaining

confi

dencea

ndincreasedreadinessfor

registe

redpractic

e.

Exploreimpactof

peer

learning

onmentorsin

the

workplace.

Chris

tiansen

andJensen

(2008)

[33]

Toexplorec

lassroom

-based

peer

learning

enablin

gstu

dentstocultivatetheir

mod

esof

expressio

n.

Voluntaryselectionfro

m288stu

dentsd

oing

third

year

commun

ication

course;16stu

dentstoo

kpartin

roleplay

and8in

focusg

roup

interview.

Observatio

nsandfocus

grou

ps.

Providetoo

lsthatcanbe

used

inclinicalpractice.Stud

ents

learnt

from

each

othera

ndappreciatedbeingableto

experie

nced

ifferentroles.

Furtherstudy

onstu

dentse

motional

learning

durin

gperio

dsof

clinical

practic

e.

Coo

keand

Moyle(2002)

[27]

Toexplorea

ndevaluatethe

useo

fPBL

over

aone-m

onth

perio

din

programmethat

uses

CLL.

130stu

dents—

100

respon

dedto

questio

nnaire.

Openendedqu

estio

nnaire.

Gavem

orec

ontro

loverlearningandaddedrespon

sibility,

prom

otingindepend

ent,self-directed

learning

.PBL

was

enjoyable.

Non

ementio

ned.

Daley

etal.,

(2008)

[20]

Toevaluateap

eer-tutorin

gapproach

toteaching

desig

ned

tomeetn

eeds

oftwodifferent

levelsof

students.

Allfirstyear

andsome

senior

studentsina

leadership

and

managem

entcou

rse.

Observatio

ns,con

ferences,

focusg

roup

s,andjournals.

Multip

lelevelsof

evaluatio

n.

Assig

nmento

fhighera

cuity

patie

ntstofirstyears.

Con

fidence

ofweakerstudentsincreased.B

etter

understand

ingof

roleof

team

mem

ber,im

provem

entin

cogn

itive

andmotor

skills,increasedcomfortin

asking

questio

ns/disc

ussin

gconcepts,

andaw

arenesso

fafuture

roleas

mentor.

Additio

nalw

orkand

form

alevaluatio

nof

programme.

Horne

etal.

(2007)

[25]

Toevaluatestu

dent

and

facilitator

perspectives

ofhybrid

mod

elof

prob

lem-based

learning

.

All121secon

dyear

studentsa

nd15

facilitators.

Focusg

roup

interviewsa

nduseo

fFou

rthGeneration

Evaluatio

n(nom

inalgrou

ptechniqu

e).

PBLaideddevelopm

ento

find

ependent

learning

skills,

self-aw

areness,andconfi

dences

kills.Improved

interpersonal/c

ommun

icationskillsb

utdepend

edon

grou

pcollabo

ratio

nandconcerns

abou

tteamworkand

grou

pdynamics.

Furtherstudy

ofeffectiv

enessfor

large

grou

psof

students

>100.

Loke

and

Chow

(2007)

[23]

Tofacilitatethe

developm

ent

of“coo

perativ

elearning”

amon

gnu

rsingstu

dents

throug

hpeer

tutorin

g.

Voluntaryselectionof

14third

year

studentsa

stutorsand16

second

year-studentsa

stutees.

Focusg

roup

sand

individu

alinterviewsa

thalf

way

andendof

10-w

eek

tutorin

gperio

d.

Positives

inclu

dedenhancem

ento

fdeeplearning

,critical

thinking

,problem

solving,commun

icationskills,

confi

denceinow

nlearning

,and

timem

anagem

ent.

Negatives

inclu

dedparticipantsbeinglateo

rfeelin

gof

not

having

adequatekn

owledgetosharew

ithon

eano

ther

and

mism

atched

person

alities.

Furtherstudies

toexam

ine

peer-tu

torin

geffects

onstu

dentsinall

years.

Morris

and

Turnbu

ll(200

4)[26]

Toexplorev

iabilityandvalue

ofusingstu

dent

nurses

asteachersin

inqu

iry-based

nursingcurriculum

.

Apu

rposives

ampleo

f240stu

dent

nurses

(36%

)participated

ininterviews.

Focusg

roup

interviews,

field

notes,interviews

audio-taped,transcrib

ed,

andanalyzed

using

them

aticanalysis.

Stud

entn

ursesw

ereu

ncom

fortablewith

thismetho

dand

thou

ghtitm

ostly

inapprop

riate,alth

ough

itmay

beapprop

riatein

somec

ircum

stances.U

seof

parallel

resource

sessions

inan

onfacilitated

forum

isprob

lematic.

Participantsdidno

tthink

thatskillsw

eretransferable.

Furtherresearch

requ

iredon

theu

seof

studentsa

steachers.

Roberts

(2008)

[18]

Toexploreifstudentslearn

from

each

othera

ndho

w,when/where

thistakesp

lace.

Voluntaryselectionof

15stu

dents.

Audio-tapedconversatio

nsof

studentsa

ndfield

notes;

them

aticanalysis.

Friend

shipsa

reim

portanttolearning

.Peerlearningin

clinicalpracticeisinformalandconsidered

partof

thejob.

Ithelped

studentstoaskqu

estio

nsandcontrib

utetothe

ward.Stud

entswerea

pproachablea

ndhadmoretim

efor

teaching

.Studentsv

aluedpeersinclinicalsettin

ghelping

each

othertocope

with

demands

ofclinicalpractice.

Replicates

tudy

with

otherg

roup

sof

studentsindifferent

locatio

nsand

branches

ofnu

rsing.

6 ISRN Nursing

Table5:Mixed

metho

dstu

dies.

Year/autho

r/Aim

sSetting

Participant

selection

Assessment

measures

Outcomes

Generalizations

and

limitatio

nsSuggested

research

Brosciou

sandSaun

ders

(2001)[24]

Toim

plem

enta

strategyto

redu

cestu

dent

anxiety

durin

gtheirfi

rst

clinicalexp

erience.

Junior/seniory

ear

studentsin

universityin

USA

20senior

students

and25

junior

students.

Con

venience

sampleo

fall

studentsinyear.

Group

interview

andLikertscale

survey:scalehad

statem

ents

presentedas

descrip

tionof

student

experie

nces.

On5-po

intL

ikertscale(onlymeans

repo

rted)

studentsreporteddecreasedsenseo

fanx

iety

(mean4.29),increasin

gconfi

dence(mean

4.08),im

proved

organizatio

n(m

ean3.91),and

perceptio

nof

beingam

embero

fthe

team

(mean3.83).Senior

studentsp

racticed

leadership

skill

(mean4.53),establish

edpriorities(mean4.4),and

developedplan

ofcare

(4.4).Re

iteratedam

ount

learnt

bysenior.

Impactof

coachdecreasedin

subsequent

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n.

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plea

ndvoluntaryselection

limits

generalization.

Furtherstudy

bymod

ifyingand

different

sites

andlarger

sample.

Feingold

etal.(2008)

[32]

Toevaluatestu

dent

perceptio

nof

team

learning

andeffect

oncla

ssinteraction

andengagement.

Firstyearstudent

nurses

ata

universityin

south-western

USA

Firstyearstudents

incourse.

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venience

sample:for

interview—10%,

respon

ses—

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nand

interviews

(Qualitative).

STRO

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(Quantitativ

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oted

student

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andwas

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inantly

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05minutes,m

oststudentsw

eree

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for8

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timeb

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%of

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behaviou

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Recogn

ized

benefit

ofdiscussio

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prob

lems.

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oncept

couldbe

generalized.Small

samplem

ayno

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representativ

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rst

year

students

(non

rand

om,

self-selected).

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tohelprefin

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learning

process

andto

guide

implem

entatio

nof

interactive

learning

strategies.

Goldsmith

etal.(2006)

[7]

Toexploreimpact

ofpeer

learning

onanxietyof

firstyear

student

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whenun

dertaking

clinicalskills

assessments.

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rdyear

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Practic

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stralia

(Con

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ndtwo

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timeframe.First

year

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ncompleted

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ajority

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orelikely

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ate

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fassessmenttoo

lwith

notallstu

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estio

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which

may

noth

ave

been

representativ

e.

Not

repo

rted.

Tiwarietal.

(200

6)[31]

Tocompare

effects

ofprob

lem-based

learning

and

lecturing

approaches

ondevelopm

ento

fstu

dents’critical

thinking

.

Firstyearstudent

nurses

inon

eun

iversityin

Hon

gKo

ng

All79

studentsin

firstyear

rand

omly

assig

nedto

control

andinterventio

ngrou

ps.P

BL=40

,CL

L=39.Selectio

nby

ballo

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Multiv

ariate

regressio

n,1and

2samplet-te

sts.

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nificantd

ifference

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initialtesting(𝑃=0.48).2n

dand3rddata

collectionpo

intsshow

edsig

nificantd

ifference

inoverallC

CDTI

scores

betweenPB

Land

controlgroup

s(𝑃=0.0048,𝑃=0.0083).Th

e4thcollectionpo

intsho

wed

high

erscoreo

ntheC

CDTI

forP

BLgrou

pbu

tnon

significant

difference(𝑃=0.1159).PB

Lstu

dentsfou

ndtheirc

oursem

oree

njoyable/in

spiring

than

lectureg

roup

.

Onlyon

euniversity

andas

mallsam

ple.

Results

may

have

been

influ

encedby

howlectures

were

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ucted.Use

ofself-repo

rtingtool.

Mon

itorin

gof

grou

pscritical

thinking

insubsequent

years.

ISRN Nursing 7

examined how the participants felt about a different methodof learning and how it impacted on them. These opinionswould be important if peer learning was to gain acceptancefrom the students and peers. Qualitative studies had muchsmaller participant numbers and whilst larger numbers mayhave provided a more comprehensive sample, there weresaturation and repetition of concepts even with the smallersamples.

Experimental studies with the highest level of evidence,that is, random controlled trials (RCTs), were not a commonmethod of evaluating peer learning as they may not repro-duce the true situation in an educational setting [34].

Eight studies used a comparison group [21, 22, 27–31, 35],and all except two [27, 31] were quantitative studies. Validtools were used by 9 of the 10 quantitative or mixed methodstudies. It was concluded that valid tools measured what theauthors intended, and hence data were an accurate represen-tation of what had occurred and were credible. However, onestudy [21] failed to report the number of control and interven-tion group participants who passed their course.The qualita-tive studies documented the research process clearly, and thefindings were consistent with the data provided. The detailsin description of the research process and findings variedbetween studies, whilst within individual studies, sample size,location, and the subjects taught were all potentially limiting;for example, small sample size, specific location, or subjectmay have caused a bias in the results, hence affecting thetransferability of results [24, 31]. Publication bias was notevident as the included studies reported both the positive andnegative results, for example, using comments from partici-pants [26] or differences in means [35].

3.2. Effects of Peer Learning. Peer learning encouraged inde-pendent study, critical thinking, and problem solving skills. Itcould give students a sense of autonomy when they acceptedresponsibility for their own education. Peer learning wasassociated with increased levels of knowledge in a number ofareas such as problem solving and communication [20, 25].Tiwari et al. [31] showed that critical thinking was improvedin students using PBL (𝑃 = 0.0048) whilst Daley et al. [20]reported that students showed improvement in cognitive andmotor skills. An advantage of peer learning was that bothgroups learned and benefited from the interaction [23, 24].The benefits differed between the students and peers with thepeers gaining experience in communication and leadership,reinforcing their prior learning and discovering what theywere capable of achieving in the mentoring/teaching fields[19, 24]. On the other hand, students gained confidence andexperienced a decrease in anxiety when dealing with certainsituations such as clinical placements. PBLwas reported to beeffective particularly in the theoretical learning component ofeducation whilst peer tutoring, peer coaching, peer mentor-ing, and the use of role play as a form of peer learning wereall effective, both in clinical and theoretical aspects of nursingeducation.

One negative aspect was related to anxiety levels. Grouplearning showed an increase in anxiety in both control andintervention groups [35], whilst other methods such as peer

coaching showed a decrease in anxiety in the clinical setting[24].The students indicated that having another person assistthemdecreased their anxiety levelswhichwas pertinentwhenthey were beginning their careers and were uncertain andanxious about what was expected of them [18]. Informal peerlearning also benefited the students by providing them with“survival” skills that are not taught in lectures or text books,which in turn assisted in decreasing anxiety [18].

In addition to decreasing anxiety [24], many studentsshowed an increase in satisfaction when peer learning wasused [22, 29], appreciating having to think for themselves,problem-solve, andwork as a team [20, 24, 27, 30].The level ofsatisfaction is higher with peer learning [29] than the passiveCLL method although some students still prefer CLL as itmaybe better suited their individual learning style [22].Whilst none of the studies in this paper directly investigatedthe link between course satisfaction and academic results,Higgins [21] noted a decrease in attrition rate but did notspecify student satisfaction levels.

Four studies [20, 23–25] examined confidence in studentswhen utilizing peer learning. They showed a subjectiveincrease in confidence levels when completing clinical skills,problem solving, and critical thinking. In addition, 11 stud-ies indicated that students appreciated interactive learningsessions and the emphasis on active participation, whichencouraged them to take ownership and responsibility fortheir own learning.

3.3. Utilization. Peer learning was utilized in multiple sit-uations from teaching ethics [22] and critical thinking [31]to helping students deal with emotional situations [19] withpatients. In clinical situations peer learning was successfuland improved integration into the ward situations [18] andstudents’ confidence when dealing with actual patients ratherthan a simulator [20]. Further, a number of studies identifiedoutcome measures showing an improvement in either anobjective or subjective assessment.

4. Discussion

The purpose of this research was to ascertain whether under-graduate nursing students benefit from peer learning. Sixteenof eighteen studies demonstrated positive aspects to peerlearning with outcome measures showing improvement ineither an objective effect or a subjective assessment (suchas a self-rated increase in student confidence). Furthermore,learning from peers was shown to be acceptable to most stu-dents. Much of the research into peer learning concentratedon formal peer learning with the evidence supporting theconcept that peer learning may be an equally, if not more,effective method of delivering information in undergraduatenursing education.

Peer learning can be utilized to pass information to largegroups of students with less faculty member involvement.At a time when there is pressure to train more nurses andminimize costs [12], peer learning could utilize resourcesmore effectively with students teaching and supervisingmore

8 ISRN Nursing

junior students, thus decreasing the demand on the respon-sible faculty members.Therefore it may have cost benefits formanaging some aspects of nursing education; however thistheory requires further investigation as it was not the focusof any of the papers mentioned in this paper.

Regardless of any decrease in active involvement by lec-turers, the need for student supervision remains important.If peers are not knowledgeable or do not have the appro-priate skills, then they cannot accurately pass informationonto another student. The learning of inaccurate informa-tion could potentially cause issues for students when theseinaccuracies were demonstrated in exams and on clinicalplacements. Without supervision, learning may not be effec-tive as shown in an earlier study by Parkin [4] who foundthat observation and supervision were required in all peerlearning to ensure that correct and current information wasbeing exchanged.

4.1. Advantages and Disadvantages. Peer learning may resultin information being more readily accepted by a student asindividuals often turn to others who have similar experiences,for advice and guidance. This could decrease anxiety asso-ciated with learning due to familiarity of the peer with thestudent’s issues. As noted in the results, anxiety may occurwhen individuals are exposed to new concepts, whether theyare novice or proficient learners [36]. In prior research [37],peer learning helped to decrease the student’s anxiety andassisted them to fit into a ward situation and feel like partof the team. This sense of belonging has social implicationsparticularly when it is known that learning occurs moreeffectively when there is socialization [38, 39].

Further, social interaction and collaboration betweenpeer and student may have contributed to an increased learn-ing curve and acquisition of further knowledge than wouldhave occurred if students were studying independently. Thiswas illustrated in this paper with students who had been indanger of failing and had received peer tutoring [21]. Theygained additional knowledge and improved their academicresult. This method may also allow junior students toproblem-solve issues with their patients more independentlyand care for higher acuity patients, leading to an increase intheir self-confidence.This conceptwas previously reported byVygotsky [40], Aston and Molassiotis [41], and Secomb [5]who found that peer learning promoted self-confidence injunior students whilst assisting senior students with mentor-ing and teaching skills. Secomb [5] also showed that peerlearning was an effective learning tool in clinical situationswith both nursing and other health professionals. Peers per-ceived an increase in patient care competence when peerlearning was utilized. Secomb [5] noted, however, that issuessuch as inappropriate pairing of students and peers should beaddressed prior to the intervention.

Student satisfactionmay play a part in scholastic achieve-ment through acceptance of an active learning method suchas peer learning. Four studies investigating this component[22, 28–30] discovered that students were satisfied with peerlearning as the educational method. This may be because thestudent takes more responsibility and actively participates in

their education, giving them a sense of autonomy. WhilstOzturk et al. [28] reported a higher satisfaction level with PBLbut no significant difference in academic scores, previousstudies have shown a positive association between studentsatisfaction and grades achieved [42, 43].

Peer learningmay also bemore successful when peers areclose in experience or stage of training as it provides a morerelaxed, less intimidating,more “user friendly” learning expe-rience than sessions conducted by registered nurses. Priorto the current study, El Ansari and Oskrochi [44], Eisen [45],and Secomb [5] also reported this finding whilst morerecently Bensfield et al. [46] reported that first year studentshad comfortable learning with more experienced peers.

There is, however, a different perspective. Whilst peerlearning has been used for years and might be becoming thenorm, students may not be fully familiar with it and there-fore be apprehensive about what it offers. Some studentsreported anxiety and apprehension when taking part in peerlearning which was linked to feeling responsible for another’seducation [25, 26], being underprepared [23] or concernedthat their own grades would be negatively affected by groupwork or dynamics [25, 26, 32]. Further, it was reported thatenforcing the educational role of a peer may lead to resent-ment, particularly if the nurse felt unprepared or unwillingto undertake the role [26]. Previously Bensfield et al. [46]showed that whilst nurses have a responsibility to teachothers, many are reluctant to do so as they feel unprepared forthe role. Due to these issues, students who are familiar andcomfortable with CLL may continue to prefer this learningmethod over peer learning.

4.2. Confusing Terminology Used in Peer Learning. Finally,this paper raises issues around the confusing terminologyused to refer to peer learning. As mentioned, multiple termssuch as peer teaching, peer mentoring, and peer coachingwere used interchangeably with debate about whether theymeant the same thing or referred to subtle differences inmeaning. A clearer definition of each of the terms is needed toincrease the rigor of nursing education research, as was alsoraised by Secomb [5], Eisen [45], and McKenna and French[47] who found a lack of clarity as to what peer educationentailed due to the interchanging of terminology. We suggestamalgamation of some of the terms, for example, team learn-ing and cooperative learning or peer mentoring and peercoaching and having distinct differences in definitionsbetween other terms.

5. Limitations

Some limitations of this study were recognized. Only studiespublished in English were included. Despite a rigorous searchstrategy, some relevant articles may have been omitted owingto the search terms used. The mix of study designs andvarious methods of reporting meant that direct comparisonbetween studies was limited. Some studies were location- ortopic-specific, and some studies collected data using indirectoutcomemeasures. However, the collection and review of thediverse papers that were selected offered the best option for

ISRN Nursing 9

determining the overall impact of peer learning in educationof nursing students.

6. Conclusion

Peer learning: learning from others who possess a similarlevel of knowledge, is becoming a part of nursing education.This study showed that undergraduate nursing students couldbenefit from peer learning, with an increase in confidenceand competence and a decrease in anxiety. Their peers alsogained skills to prepare them for their role as a registerednurse. Conduct of peer learning within the curriculum wasshown to require adequate academic supervision to be effec-tive. It was difficult to ascertain the most effective learningmethods because of the inherent variation between studymethodologies, terminology, subjects, and settings. Inconsis-tency terminology was identified as a problem that should beaddressed in order to provide clarity in future research.

7. Further Research

Further research is needed to fully investigate peer learningwith the use of larger samples, various targeted curricula,courses, and locations to increase the validity of studies. Thecost effectiveness of peer learning should be further inves-tigated and compared to that of CLL to ascertain how thisoption could impact nursing education in terms of resources,time management, and effectiveness.

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