A peer learning intervention in workplace introduction - managers’ and new graduates’ perspectives

Transitioning into a new professional role is challenging. While many new graduates adapt effectively to their workplace, others may struggle to manage these demands [1]. Studies have reported that new graduates who have the opportunity to meet, socialize and share experiences assist each other in coping with stress [2]. Furthermore, that having a peer involved sharing and acknowledging each other’s experiences and feelings, asking each other as they say “stupid questions”, and admitting to shortcomings and worries, all of which reduced feelings of stress and anxiety [3]. The present study is part of a research project designed to investigate new graduates’ pathways into the profession. It focuses on the use, feasibility and effects of peer learning. The conclusion from our earlier feasibility study was that the peer learning intervention seemed to be feasible in the study context [3]. The present study is an extension and aims to look at the process and effect of using a peer learning intervention in workplace introduction for new graduates. Boud’s [4] theoretical description of peer learning guided the intervention and Medical Research Council (MRC) framework of complex interventions and the concept of process evaluation [5, 6] were used to guide the study design.

Peer learning is a pedagogical model that originates from theorists of social learning such as Bandura [7]. It is based on the idea that experience, understanding, and knowledge are built and developed in interactions between humans. According to Boud [4] peers learn from each other’s insights and understanding, reasoning, and actions through communication. To our knowledge, there are no previous studies focused on using peer learning as a deliberate support strategy in new graduates’ transition to work, except of Pålsson et al. [3], whilst studies on nursing students using peer learning during clinical practice are several. Studies mostly shown positive outcomes and advantages, as belief in oneself and increased self-efficacy [8], confidence [9‐11], development and clinical knowledge [10, 12, 13], capacities also desirable among new graduates. Students have report that working together and supporting each other reduce stress and anxiety [10, 11]. Furthermore, when they are introduced to staff and face new clinical challenges, they feel safer and less nervous being with a peer [14]. Few limitations associated with peer learning have been described, but students have reported disadvantages, such as having to share scarce resources with the peer [15] and reduced learning when personalities or learning styles clash [10, 16].

The importance of relational aspects in facilitating transition (support from other nurses’ peers, mentors and preceptors) were revealed in a review by van Rooyen et al. [17]. Further, a mixed-methods study [18] demonstrated that self-efficacy, job satisfaction, stress and structural empowerment were factors affecting new graduates’ transition. The facilitators, which supported the quantitative findings, were self-confidence, interaction with colleagues, positive and supportive work environments, and a transition program. According to Spreitzer [19] a supportive peer relationship played an important role in facilitating empowerment. Kuokkanen et al. [20] reported a positive relationship between new graduates’ assessment of empowerment and professional competence, job satisfaction and satisfaction with the quality of care. Furthermore, relational aspects have shown to have positive impact in new graduates’ job satisfaction [21]. A review by Hawkins et al. [22] indicated that new graduates not prepared for situations in which professional and organizational constraints influence their work, results in feelings of unpreparedness that cause lack of confidence as well as feelings of uncertainty, anxiety and stress. Earlier studies found that new graduates (peers) who have had the opportunity to meet, socialize and share experiences in a group were better able to cope with stress [2, 23].

Besides support from other nurses, first-line managers have been reported to be important in new graduates’ transition into the workplace. A qualitative study showed that new graduates and managers identified similar factors that facilitated transition [24]. Managers are important in the process of testing new aspects of new graduates’ introduction. The managers recruit and hire new graduates for the wards and are responsible for their workplace introduction. In an earlier quasi-experimental study, Henderson et al. [25] reported on the importance of first-line managers’ engagement for the success of practice interventions, as first-line managers contextualize projects for their staff.

In the present study, process evaluation and the MRC framework provide guidance for the study design. The MRC framework can be helpful when developing, evaluate and implement complex interventions [5, 6]. The complex intervention of peer learning involves two new graduates undergoing workplace introduction together. The pair of new graduates share a preceptor and are therefore able to support and learn from and with each other as well as with the preceptor and the team. This introduction is different from the traditional one in which one preceptor guides one new graduate. Complex interventions are described as interventions that contain several interacting components, where these components may interact with the context during intervention delivery [6]. The peer learning intervention consisted of several components, and adding peer learning to the existing introduction program affected, e.g., the new graduates, first-line managers, preceptors, and colleagues, such as other nurses and nurse assistants. To evaluate the effect of an intervention, a randomized controlled trial (RCT) design is generally regarded as the gold standard when randomization is feasible. However, evaluations are often described as being diminished by difficulties regarding acceptability, compliance, delivery of the intervention, recruitment and retention [5]. In the updated version of the MRC framework, greater attention to the context in which interventions take place has been added. The aim of a process evaluation is to provide a more detailed understanding of a complex intervention. The findings can help us understand the casual assumptions supporting the intervention and how interventions work in practice [6].

To sum up, it is important to support new graduates during the first period so as to build relationships that increase their patient care capacity, confidence, competence and job satisfaction. It seems reasonable to assume that new graduates could achieve the same positive outcomes of peer learning as described by nursing students and an earlier feasibility study support that new graduates’ descriptions of peer learning during their workplace introduction was concordant with the theoretical model [3]. Based on earlier studies, our assumption was that peer learning that includes working and learning together and supporting each other [10, 11] should influence new graduates’ learning and development as well as belief in themselves, thereby increasing their satisfaction and well-being (Fig. 1). However, more research on employing peer learning in the context of workplace introduction is needed, and the present study can contribute to this area. Nevertheless, complex interventions in healthcare are often related to problems such as difficulties with standardizing the design, delivering the intervention and being sensitive to structures of the local context [5]. Thus, to provide a more detailed understanding of the intervention, a process evaluation was conducted alongside the effect evaluation.

The group interviews with managers revealed that there were practical problems when standardizing the intervention, but on the whole there were mostly positive descriptions of using peer learning during new graduates’ workplace introduction. Further, fidelity to the intervention was relatively good, and most followed the intervention components. However, during the latter part of the intervention period, the new graduates had problems taking time for joint reflection. The ES measured as Cohen’s d showed that 29 variables had a small or medium effect size with some mean differences in favor for the intervention group and some for the control group. As a consequence of recruitment problems (small sample sizes), it is difficult to draw conclusions concerning peer learning effects on new graduates. We can only add to the MRC statement that even at later stages in the development of complex interventions, process evaluations are important, as in present study, in considering the context of recruitment problems previously not identified.

Although there were problems in evaluating the effects of this peer learning intervention, the results from the interviews with the managers support the concept of two new graduates learning with and from each other during their workplace introduction. Managers’ experiences of peer learning have not been included in previous studies, although they are important individuals with responsibility for the work environment on their wards. In the study, the managers described themselves as having positive attitudes toward the intervention and experiencing several positive outcomes of using peer learning in new graduates’ introduction. The positive results described were that the pairs both learned while cooperating and learned how to cooperate. Furthermore, the managers found the pairs to be independent, and they noticed that the pairs supported and helped each other even after the intervention ended. This, in turn, was described as generating in the new graduates feelings of security and as giving the pairs the courage to ask questions and make demands. Similar positive outcomes, like those described by managers, have previously been reported by nursing students [14, 43], preceptors [44, 45] and new graduates [3, 46]. Interestingly, the managers’ descriptions of pairs giving each other the courage to ask questions and make demands are in line with data from interviews with new graduates using peer learning [3]. The managers’ experience of negative outcomes related to incompatible pairs has also been described by students [10, 16] and preceptors [44]. However, findings from a recent observational study showed that incompatible pairs of nursing students also practiced several competencies together, such as communication, reporting skills, organization of nursing care and leadership [16].

When measuring intervention fidelity, the results showed that participating pairs generally followed the intervention well. However, during the interventions last 2 weeks, only three pairs of new graduates took time for joint reflection. Reported reasons for not reflecting were, e.g., high workload and lack of time. Although the managers experienced the new graduates’ joint reflection as positive, they described difficulties getting the new graduates to prioritize that after the first 3 weeks. Furthermore, nine of 16 considered the joint reflection to be important to their professional development, and in previous peer learning studies peer reflection has been described as beneficial [3, 47]. The importance of managers’ involvement for intervention success was described in a previous study [25]. Moreover, an interview study on managers revealed the importance of reflection for new graduates’ learning and development [48]. One explanation for not taking time might be that new graduates do not want to be singled out for going away to reflect, as previous studies have reported on the importance of new graduates maintaining interpersonal relationships with colleagues [17, 49]. However, the first period of working in the nursing profession is described as associated with feelings of stress [50], where joint reflection might reasonably be supportive.

During the data collection in the experimental part of the study, it became obvious that the study had recruitment problems. The estimated sample size to be recruited was 76 pairs (152 participants). In the region, about 220 nurses graduated from the nearby university annually. During the recruitment of participants, i.e., between June 2015 and June 2018, 338 nurses were employed at the 22 eligible hospital wards. Of the estimated sample size of 152, 44 were recruited for randomization and 35 completed the baseline questionnaire. This was a surprise, and for this reason no concerns about the complexity of recruitment had surfaced in the feasibility study or in the steering group. In the earlier feasibility study [3], there was no problem recruiting pairs to the study, and there were no concerns about the complexity of recruitment in the steering group. In the group interviews, the managers reported not having the opportunity to participate in the study because the new graduates did not begin their workplace introduction at the same time and thus could not form pairs. This issue and being randomized to the control group were described as problems, because the managers were eager to test the intervention. Despite the great strength of an RCT, the study could have benefited from using a quasi-experimental design in which all new graduates that formed a pair would constitute the intervention group, and the comparison group would include new graduates starting their introduction alone. Considerations of alternatives to RCTs are also described in the updated version of the MRC framework. Furthermore, they suggest that even when a process evaluation has been conducted at the feasibility stage, another will usually be needed for the full trial, because new problems are likely to emerge when the intervention is tested in a larger more diverse sample [5, 6]. However, it is still important to publish “failures.” The World Health Organization (WHO) stated in a public disclosure [51] that about 50% of clinical trials go unreported, often because the results are negative. These unreported trial results leave an incomplete and potentially misleading picture of the risks and benefits of interventions.

Process evaluations are important when developing and evaluating complex interventions. The study found positive experiences of and fidelity to the peer learning intervention. Regarding the experimental design, there were lessons learned, something also confirmed by the interviews with managers and stated in the MRC framework. Moreover, even after a feasibility study, when the process goes on to the next stage using an experimental study design, it is of great value to conduct a process evaluation to explore the interactions between context and study design that sometimes first emerge during the scale-up, which is also a result.