Swedish student nurses’ perception of peer learning as an educational model during clinical practice in a hospital setting—an evaluation study

Clinical practice is a vital part of nursing education, and highly valued by student nurses [1]. Learning in clinical practice has traditionally involved one student nurse being precepted by one registered nurse, where the preceptor has tried to mediate knowledge and skills to the student. Previous studies have shown that preceptorship is time consuming with no real reduction of clinical work for precepting nurses [2, 3]. From a student perspective, the clinical environment can be perceived as stressful and not welcoming [4, 5], especially in a hospital setting [6] therefore, the relationship between the student and the preceptor is fundamental to the learning process [7]. However, in Sweden, as well as internationally the increasing number of student nurses subsequently leads to a pressing need for additional preceptors and clinical placements [8]. This coincides with financial pressure on healthcare services and declining retention rates of registered nurses. To address these challenges, new educational models for learning in clinical practice need to be implemented and evaluated. One way forward might be peer learning, a collaborative educational model, where students from the same social grouping learn from and with each other [9, 10]. The peer learning model is based on the assumption that learning is constructed during social interaction in collaboration with significant others inspired by Piaget’s and Vygotsky’s theories [11]. The model is often referred to as the 2:1 clinical placement model, were two students are placed with one preceptor to overcome placement shortages [12]. Students are active and equal partners sharing learning activities and participating in discussions and feedback [13]. In nursing programs, the model is often referred to during clinical practice in hospital settings [14‐16], and the most common model of peer learning is when a senior student acts as a tutor for a novice student [17]. However, it has been suggested that a more favourable approach is to combine students from the same year as this will allow students to alternate the roles of tutor and tutee, and motivates students to become more involved in their own learning [17].

The effects of peer learning have been described in systematic reviews [13, 18]. Positive effects such as increased cognitive skills, self-confidence, autonomy, clinical skills and reasoning are highlighted. Furthermore, and perhaps more difficult to evaluate in other educational models, are increased self-evaluating skills, collaborative- and leadership abilities [13], critical thinking [15], and the opportunity to share the experiences of a fellow student without the immediate interference of the preceptor [19, 20]. However, some adverse effects have also been described, including students not being compatible with each other, not wanting to compete for clinical tasks, having to share the preceptor’s attention and time, and having less time to practice independently [13].

Clinical placements in hospital settings are learning environments that include several categories of staff, constant shift changes and patients with complex medical- and nursing needs. In this demanding environment, student nurses are supposed to link theoretical knowledge to practical skills, and to demonstrate initiative, independence and work management skills. On the other hand, preceptors are expected to balance complex patient care with precepting of high quality [2]. This highlights the need for a supportive educational model in hospital settings, supporting students and preceptors as well as being cost beneficial. Peer learning has no tradition in clinical education for undergraduate student nurses in Sweden and little is reported of the student experience. The objective of this study was to explore how student nurses’ evaluated peer learning as an educational model during clinical practice in a hospital setting. Furthermore we wanted to investigate whether nurse students perceived peer learning differently with regards to being a novice student in year one or being at the threshold of graduation in year three.

For this evolutional study, data were collected by using a questionnaire.

The study group consisted of 135 students, the majority were female (n = 107). The percentage of male students (18.5 %) is slightly higher than the ratio of Swedish male registered nurses. The participants were between 18 and 50 years old (mean 26). Sixty-two students were in their first year and 73 in their third year (Table 4).

Overall, the student nurses were positive of the peer learning experience. The highest mean values were computed for the questions Were the peer learning activities relevant for your coming profession as a registered nurse (3.40) and Was your preceptor properly prepared for the peer learning activities (3.37). The lowest score (2.77) was measured for the question Were you properly prepared for your teaching function.

We examined if any statistical differences existed between the two sub-groups, namely students in year one and year three. Out of the eight questions two were statistically significant (p ≤ 0.05). The questions To what extent did you learn during the peer learning activities and Were the peer learning activities relevant for your coming profession as a registered nurse proved to be statistically significant with more positive evaluations for students nurses in year one (Table 5).

The categories that emerged from the open-ended questions of the student evaluations were: A feeling of safety, The learning experience and finally A sense of competition. Quotations are presented below in an attempt to illustrate students’ experiences.

Although the majority of students seemed to be satisfied with the peer learning experience there is a tendency that year one students are slightly more positive than the final year students. The questions To what extent did you learn during the peer learning activities and Were the peer learning activities relevant for your coming profession as a registered nurse were statistically significant, displaying more positive value for year one students. This can probably be explained by the fact that as a novice, more structured activities are needed when developing nursing skills [24]. We suggest that this can be contributed to how the structured learning activities, used in the peer learning model, realistically mirror the content comprising the nursing profession. It is also possible that the structure activities provide a safe learning environment when students know what is expected of them. The thematic analysis illustrates that the peer learning model strongly contributes to students’ feelings of being safe in a clinical environment. A safe clinical learning environment has been described in previous studies as “to ask anything” culture [25], “decrease in anxiety” [19], and “feeling comfortable in the learning relationship” [14]. We argue that a safe clinical learning environment made possible by peer learning, most likely contributes to increased learning, in line with Roberts [25] who recommended friendship as an important factor enhancing learning. Students learn a great deal by explaining their ideas to others and by participating in activities in which they can learn from their peers [10, 18]. This is explained in the present study by students perceiving a high degree of self-confidence, independence and increased learning by participating in the peer learning model. As suggested elsewhere [26, 27], and supported by the current findings, clinical education programs need to manifest the positive consequences of peer learning and integrate the model in clinical education.

However, even though the peer learning model seems to be beneficial to the students’ learning experience in clinical practice, some negative aspects were presented and need to be acknowledged. These aspects were related to students not feeling properly prepared to teach a fellow students as well as the presence of competition. In the current study, the students described how the initial feeling of safety sometimes turned into frustration when students competed for the preceptor’s attention, opportunities to perform nursing interventions or when student realized that they had different learning styles. The issues of competition and non-compatible students have been identified as major concerns for nurse educators in previous studies [13, 15, 18]. To avoid competition, some students in our study, suggested that they should be allowed to choose a friend as their peer, and not be randomly paired. However, as presented earlier this was not an option for the students in the present study, the reason being that the ability to collaborate in a health care team is fundamental to provide high quality care. Therefore, students need to practice collaboration based on a professional relationship rather than on friendship. What seems to be missing though, are educational strategies directed towards the negative aspects of competition. Therefore, we suggest that students are theoretically introduced to peer learning as an educational model prior to clinical practice. The introduction should include a presentation of the structured activities and how they can support the learning experience, as well as being supportive for the teaching and learning sessions between the peer. Furthermore, the aspect of competition needs to be acknowledged, and openly discussed to prepare the students, should this issue arise during collaboration. One needs to bear in mind though, that competition can be favourably for learning as students from the same year can compare their knowledge and skills. The comparison between the peers can act as a trigger that further students’ motivation to learn.

We acknowledge the fact that the results are interpreted in the light of the limitations that might occur in connection with a limited convenience sample in a single setting as well as the nature of self-reporting on variables and are therefore not generalizable. No general conclusions can be drawn as the evaluation only measures students’ reaction on the teaching methods according to Kirkpatrick [28].

The peer learning model seems to have the potential to be a sound educational model complementing the more traditional ways of supervision in clinical practice, for example, the one student-one preceptor model. A feeling of safety seemed to be connected to the increased learning experience as it supported the students’ perception of independence. On the other hand, the sense of negative competition needs to be addressed when students are prepared for the teaching and learning activities in the peer learning model. The introduction should include a presentation of the structured activities and how they can support the learning experience as well as being supportive for the teaching and learning sessions between the peer. However, what need to be further investigated are what challenges and opportunities the peer learning model presents to preceptors, therefore, to be able to understand the full implications of peer learning we propose further studies exploring the experiences of preceptors.