Learning never stops: Evaluation of peer teachers in high fidelity simulation

Abstract

Background:

Nurse educators have used peer teaching as a means of providing effective learning to peer learners and enhancing peer teachers’ comfort with teaching. There is a lack of evidence related to providing feedback to peer teachers. Receiving feedback may enhance peer teachers’ knowledge synthesis and understanding of the teaching process.

Methods:

We utilized a mixed methods approach to determine if an evaluation instrument was valid and helpful to peer teachers. Both peer learners and educators completed evaluations of peer teachers, which were then compared. After receiving summarized feedback, peer teachers completed a survey regarding their experience.

Results:

There were no statistical differences between peer learner and educator ratings of peer teachers. Peer learners indicated they found peer teachers to be helpful in the high fidelity simulation setting. Peer teachers indicated satisfaction with the experience. Analysis of qualitative comments on peer-teacher surveys resulted in the identification of three themes: (a) validation of knowledge growth; (b) increased comfort with teaching; and (c) enhanced appreciation of teaching.

Conclusions:

Peer teaching may enhance knowledge gain and synthesis for both peer teachers and peer learners. Enhanced comfort with teaching may lead to enhanced comfort in teaching both patients and peers in future practice.

1 |. BACKGROUND AND SIGNIFICANCE

Peer teaching in nursing education provides a number of advantages for students in the roles of peer teachers and peer learners. Peer teachers are nursing students who are at a similar stage in their nursing education and serve as teachers or mentors for other students. Peer learners are nursing students who are acquiring knowledge or skills with the assistance of peer teachers. This working relationship between peer teachers and peer learners is dynamic. Research shows that peer teachers report increased confidence in their own knowledge of didactic content and the performance of skills.^1,2 Stone et al³ noted that peer teaching was as effective in the view of peer learners as faculty-led teaching in a number of settings, including clinical practice sites and skills labs. In a study conducted with peer teachers in high fidelity simulation (HFS) Lawrence et al⁴ noted that peer teachers reported the improved synthesis of knowledge gained from didactic courses, clinical experiences, and simulations. They attributed this synthesis to the experience of teaching in the safe environment of HFS. Peer teachers also reported increased awareness of the continuum of novice to expert in both peer teachers and learners.⁵ McKenna et al⁶ noted learning occurred beyond that intended in a skills laboratory setting, with participants reporting knowledge gain extending to socialization into the profession.

While researchers report numerous advantages for both peer teachers and learners⁷ there remain significant gaps in the literature. One of these gaps is effective evaluation and feedback for peer teachers. While faculty typically evaluate learners in simulation with formative, summative, and/or high stakes methods, we found no reports of formal evaluation of peer teachers by peer learners. Ramm et al⁸ noted limited research in the area of peer-teacher assessment by faculty, attributing this to the difficulty of assessing peer teachers. They observed that faculty utilized learner outcomes to evaluate peer teachers by proxy. In order for peer teachers to gain full value from the peer teaching experience, it is essential that faculty provide feedback to peer teachers. This feedback would be valuable in assisting peer teachers to improve aspects of their peer teaching, which in turn may improve their teaching skills with patients and peers as they enter practice. The aim of this study was to explore the preliminary development and testing of an evaluation tool for peer teachers in our HFS lab. For the purposes of this study, peer teacher refers to a final semester senior nursing student who assists with skill and knowledge acquisition while peer learner refers to a junior student who is acting as the nurse in HFS. Peer learning refers to the gain of knowledge and/or skills through the support of a near equal.

2 |. CONTEXT AND SETTING

This mixed methods study was conducted at a school of nursing in the southeastern United States where faculty employed peer teaching in HFS as a leadership experience for students enrolled in a Nursing Leadership and Management course in the final semester of a traditional baccalaureate program. Faculty designed the peer-teaching encounter with the intention of offering senior students an opportunity to experience an aspect of nursing education and to replace a nurse manager shadowing experience that had previously taken place in the clinical setting.

Before the HFS experience, all peer teachers (final semester senior nursing students; N = 29) received 1 hour of education on the history, pedagogy, and practice of simulation in the classroom setting. Debriefing in accordance with the International Nursing Association for Clinical Simulation and Learning standards of best practice: simulation was specifically covered.⁹ They were also required to review a summary of the clinical case and pertinent pathophysiology as needed. The peer teachers (senior students) actively participated in the HFS and offered support and prompts to peer learners (junior students; N = 108). Peer teachers were specifically expected to give constructive and appropriate critique during debriefing. Framed by Kolb’s¹⁰ experiential learning theory, simulation offered peer teachers opportunities to practice teaching skills in the safe environment of the HFS lab.

3 |. RESEARCH METHODS

Senior course faculty and HFS faculty collaborated to develop the peer-teacher evaluation tool, completed by peer learners and simulation faculty, to provide feedback to peer teachers. This tool consisted of objective items rated on a 5-point Likert scale as well as comments (Figure 1). Researchers established face validity for the peer teaching rating form through consultation with faculty who had expertized in HFS and agreed that this survey covered important information in an easily understood way.

FIGURE 1.

Peer teacher evaluation

The university’s Institutional Review Board approved this study, and investigators informed all participants that researchers would use evaluation and survey data for research purposes. Data collection using the peer-teacher evaluation tool and feedback about the peer teaching experience in HFS occurred simultaneously using a concurrent triangulation strategy.¹¹ First, peer learners and simulation faculty responded to the peer evaluation tool. Then, researchers obtained qualitative data/feedback/responses from peer teachers.

Four peer learners and two peer teachers attended each HFS. One peer teacher stayed in the clinical case while the other went into a control room to learn more about how faculty conduct HFS. At the mid-point of the clinical case, the peer teachers switched so that each experienced both roles. Peer learners were asked to rate each peer teacher after the HFS experience by completing the peer-teacher evaluation tool on paper following the simulation and debriefing. Simulation faculty then averaged Likert scale items, summarized comments, and conveyed this information to peer teachers in aggregate form to protect the privacy of peer learners. During the period of the study, simulation faculty also completed the same peer-teacher evaluation. Investigators then compared the evaluations of peer learners and simulation faculty.

Descriptive statistics were used to summarize demographic characteristics (gender, race/ethnicity) of the student participants. Student and faculty evaluation scores for each peer teacher were averaged across all HFS sessions and t-tests were used to examine differences between student and faculty ratings on each item and the average score across items.

Researchers simultaneously collected qualitative data from peer teachers about their self-perceptions of the peer teaching experience. The peer teachers wrote responses to questions prompting self-reflection of the teaching experience (Figure 2). The first two authors engaged in thematic analysis¹² of the written responses collected in the peer-teacher evaluation of the experience. After independently coding comments, they met to discuss codes and emerging themes. Subsequently, they engaged in focused coding¹³ and concurred on major themes that will be presented in the next section.

FIGURE 2.

Peer teacher evaluation of the experience

4 |. RESULTS

Twenty-nine peer teachers and 94 peer learners participated in this study. Students in both the peer-teacher and peer-learner groups were representative of the school of nursing’s student demographics (ie, 84% female, 71% white, 22% African-American, 6% Hispanic, and 1% Asian or other). One of the three simulation faculty concurrently rated the peer learners. Posttest means for each item on the peer-teacher evaluation, as well as overall mean evaluation scores between peer learner and faculty raters are displayed in Table 1. There were no statistical differences between the peer-learner scores and the faculty scores on any evaluation item or on the overall mean evaluation score.

TABLE 1.

Means for peer-teacher evaluations

	Student scores		Faculty scores
Question	M	95% CI	M		95% CI		P value
1	4.745	4.640	4.850	4.696	4.501	4.890	.66
2	4.724	4.614	4.835	4.652	4.451	4.853	.54
3	4.704	4.582	4.827	4.696	4.465	4.926	.95
4	4.755	4.643	4.867	4.652	4.416	4.889	.44
5	4.745	4.636	4.854	4.652	4.416	4.889	.49
6	4.724	4.607	4.842	4.696	4.465	4.926	.83
7	4.816	4.720	4.913	4.783	4.608	4.967	.74
8	4.755	4.651	4.859	4.696	4.501	4.890	.60
Mean scores	4.746	4.647	4.845	4.690	4.514	4.866	.59

Abbreviation: CI, confidence interval.

Responses to the Likert scale items on the peer-teacher evaluation of experience surveys were averaged (Table 2) with means ranging from 4.59 to 4.86 out of five. Three major themes emerged from the qualitative data on the peer-teacher evaluation of experience: (a) validation of knowledge growth; (b) increased comfort with teaching; and (c) enhanced appreciation of teaching.

TABLE 2.

Means of peer-teacher evaluation of the experience

Likert scale items; 1 = strongly disagree, 5 = strongly agree	Average
1. The peer mentoring experience helped me to confirm my knowledge of nursing care	4.75
2. I was comfortable giving guidance to lower-level students	4.59
3. The feedback I received was helpful to me	4.86
4. I felt comfortable clarifying priorities with the lower level students	4.66

4.1 |. Validation of knowledge growth

Peer teachers perceived participation in HFS validated a growth of knowledge and skill during the nursing program. Receiving feedback from peer learners helped peer teachers confirm their knowledge and teaching ability. One student commented that the experience “showed me how much I learned.” Another stated, “I felt smart for once.” Although they related anxiety that they would not know an answer to a question from a lower-level student, peer teachers reported feeling that they contributed to the education of their peers in an effective manner. As one peer teacher stated, “I found it to be really rewarding because throughout nursing school you feel like you don’t know anything, yet during scenarios, we are able to give the lower level students tips and push them in the right direction…”

Another peer teacher noted how receiving feedback enhanced her confidence in her own knowledge. The student stated the best thing about the experience of peer teaching was the feedback from lower-level students about the benefits of her assistance. Other peer teachers noted that certain nursing actions had become very natural to them, allowing them to teach learners comfortably. One student stated, “They were struggling with things that seemed simple to me now.” Several noted that participating in the peer teaching experience confirmed their knowledge of specific patient conditions presented in HFS. One peer teacher stated, “I was able to reflect on the knowledge I have gained and also see how I handled the sim lab differently this time around compared to the first time, when I was a lower level student.”

4.2 |. Increased comfort with teaching

A second theme from the peer teacher’s comments was that of increased comfort with teaching. Increased validation of nursing knowledge translated to engagement in teaching peer learners. Receiving positive feedback from peer learners, in turn, enhanced their confidence to share knowledge and guide learners effectively. A number of peer teachers noted that this experience allowed them to appreciate how their leadership skills have grown over the course of their nursing education. They also attributed the growth in leadership skills to the experience of peer teaching. One peer teacher stated, “I think that the [peer teaching] experience helped me to grow in my leadership skills and also helped with my confidence in nursing care, skills, and assessments.”

A number of peer teachers noted that the experience was enjoyable. One rewarding aspect related by a peer teacher was the observation that peer learners “paid attention to what I was saying and applied it during their time in the scenario.” Another student commented that it is “humbling feeling to have other students look up to me for advice.” When asked to list specific skills that they helped with, peer teachers listed specific psychomotor skills, communication skills, and higher-order thinking skills. Psychomotor skills included procedures such as urinary catheter insertion, tracheostomy care, and insertion of a nasogastric tube. Communication skills included phone calls to the provider or teaching the patient about dietary restrictions. Higher-order thinking skills included prioritization of nursing actions. Participants noted enjoyment and increased comfort in teaching each of these types of skills. Further, one student commented, “helping lower level students also helped me learn new things.”

4.3 |. Enhanced appreciation of teaching

The final theme was the enhanced appreciation of the complexities of teaching. Several peer teachers related their appreciation of learning more about the pedagogy and process of HFS. One peer teacher noted that it was “cool to see behind the scenes in the lab, especially how students processed.” Peer teachers also readily noted that nursing education is complex, with one stating that education is not as easy as it looks. Several observed that knowing when to prompt peer learners was challenging. As part of the orientation to the experience, faculty instructed peer teachers to allow peer learners to explore possible actions and even make mistakes before prompting them to specific actions. The peer teachers reported struggling to balance the desire to provide direction but allow time for independent thinking and problem-solving. One peer teacher stated, “The most challenging part was not immediately stepping in, and allowing students time to try and figure things out themselves first.” Faculty instructed peer teachers to prompt peer learners only when they felt the learners’ anxiety to be overwhelming. Peer teachers expressed discomfort in making this judgment. Students noted that correcting others was difficult and uncomfortable.

Peer teachers also made a number of positive comments about nursing education. One peer teacher commented, “Helping lower level students [peer learners] also helped me learn new things.” Another stated, “Everything is interesting there is always something to be learned.” Resoundingly, peer teachers desired additional opportunities to interact and teach peer learners.

Peer teachers perceived some aspects of nursing education to be challenging. Among these challenges were different learning styles, different teaching styles, and the commitment to lifelong learning. One peer teacher noted that it could be difficult to teach because not everyone learns the same way that the teacher does. Another addressed the aspect of lifelong learning stating, “It never stops.”

5 |. DISCUSSION

This study of peer teaching in the HFS environment revealed a number of findings of interest to nurse educators. With regard to our primary aim, the evaluation tool demonstrated face validity, but further research, using a larger sample, is needed to explore these tools’ psychometrics. In addition, the analysis of qualitative data reveals that peer teachers found both the experience and the feedback they received to be of value to them as part of their nursing education. Peer teachers noted benefits to their HFS experiences including gaining confidence in their knowledge, becoming more comfortable with teaching in the safe environment of the simulation lab and learning more about the pedagogy of teaching with simulation.

According to Kolb et al,¹⁰ learning takes place as experience transforms into knowledge. The two modes of understanding experience, active experimentation, and reflective observation may occur readily within the experience of HFS. The experience of teaching in HFS afforded peer teachers the opportunity to create knowledge with their peers then reflect on their experiences. Participants in this study noted increased confidence in their knowledge and ability to teach because of participating in the peer teaching activity. While studies in other settings have noted similar findings for peer teachers^1,8 no other studies were found that reported on the evaluation of feedback for peer teachers. Peer teachers found this feedback helpful.

An unexpected benefit of peer teaching was that of enhanced socialization into the profession on the part of both peer teachers and peer learners. Members of both groups stated that it was helpful for them to interact with students of other levels. Peer learners noted that the opportunity to rate peer teachers helped them gain insight into the senior student role. Peer teachers, in turn, noted gaining insight into the complexities of nursing education by interacting with faculty and peer learners in the HFS labs.

Of note, the peer teachers remained confident in their knowledge and teaching role until faced with challenges such as dealing with their own anxiety, the perception of increasing anxiety on the part of the peer learners, or when correcting a peer. The peer teachers expressed difficulty in navigating their own fears while also bearing the responsibility of teaching. Furthermore, peer teachers maintained boundaries with peer learners throughout HFS experience until the peer teachers had to redirect a peer learner. The relationship then shifted from a teacher-learner to peer-peer, which both peer teachers and learners reported as difficult to navigate. During these problematic times in HFS scenarios, faculty members were able to offer guidance to both students and ultimately rebalance the teacher-learner relationship for the remainder of the scenario.

6 |. LIMITATIONS

Notable limitations include the small sample size and single site of this study. In addition, not all participants finished the evaluation survey. All peer teachers completed the peer-teacher evaluation of experience; 98 peer learners completed the peer-teacher evaluations out of 108 peer learners in total. In addition, the age of peer teachers was not assessed which could influence teaching skills and instructional capabilities. Further, the demographic data of the three faculty members were not collected which could potentially impact the environment among both the peer teachers and peer learners. Finally, three faculty rated the peer teachers, which may have added variability in interpreting the results. Further research with a larger sample size at multiple sites would enhance understanding of best practices in peer teaching.

7 |. CONCLUSION

Nurses engage in teaching in many contexts on a daily basis. They teach patients, family members, nursing students, and peers but their teaching may not always employ best practices. Experience with teaching in the context of HFS may offer the opportunity to learn teaching techniques, enhance self-efficacy, and serve to emphasize the importance of teaching. Confidence in teaching may serve to encourage nurses to engage more effectively with patients and peers in educational activities in the context of their future careers.

AUTHOR BIOGRAPHIES

Dr. Kay Lawrence is an assistant professor and director of the simulation program at the University of South Carolina Aiken. She has more than 35 years’ clinical experience, over eight years’ experience teaching with high fidelity simulation, and is a certified healthcare simulation educator. Her research program focuses on creative uses of simulation to enhance learning in undergraduate nursing education.

Dr. Katie Chargualaf is a certified medical-surgical nurse with more than 20 years of clinical experience. Currently an Assistant Professor at the University of South Carolina Aiken, Dr. Chargualaf has experience teaching medical-surgical nursing, nursing research, theory, and leadership and management in accelerated and traditional pre-licensure nursing programs. Dr. Chargualaf maintains programs of research related to nursing education, evidence-based practice, post transplantation patient outcomes, military nurses, Veterans, transition to practice, and nurse retention.

Dr. Pearman Parker is a clinical instructor for the College of Nursing at the University of Arkansas for Medical Sciences. She blends her clinical experience in psychiatric nursing with her research experience in cancer education. Dr. Parker program of research focuses on patient-centered communication in cancer, patient education, and health literacy. She is a KL2 Scholar and receives funding through the Clinical and Translational Science Awards Program at the University of Arkansas for Medical Sciences and the Arkansas Breast Cancer Research Program.

Dr. Corey Nagel is an Assistant Professor in the College of Nursing at the University of Arkansas for Medical Sciences and is Co-Director of the UAMS Hartford Center for Gerontological Nursing Excellence. His program of research focuses on chronic disease epidemiology, health behaviors, and functional outcomes among older adults.