Educational nursing programs across the globe continue to search for creative solutions to optimally prepare students for professional practice. Insufficient clinical sites, coupled with a shortage of nursing faculty and budgetary constraints, present barriers in the preparation of adequate numbers of nurses (Johnson, Butler, Harootunian, Wilson, & Linan, 2016; Ownby, Schumann, Dune, & Kohne, 2012). To address these challenges, simulation-based learning (SBL) has received significant attention believed to offer the advantage of a safe environment to learn and reinforce crucial clinical care practices (Meyer et al., 2014). Additionally, testing anxiety is a concept known to exist in nursing education (Gibson, 2014). Although research examining the impact of SBL on anxiety among prelicensure nursing students exists, little is known regarding the correlation between SBL and the reduction of anxiety for examination readiness and preparedness (Hollenbach, 2016; Horsley & Wambach, 2015). Faculty teaching in the academic or clinical practice settings would benefit from knowing what students perceive as strategies that positively influence the capacity to prepare for programmatic examinations while simultaneously reducing associated anxiety.
Peer-assisted learning (PAL) is one educational strategy that has the potential to connect SBL with preparing prelicensure nursing students for both programmatic and practice licensure examinations. Incorporating PAL within an existing simulation program might also ease burdens professional nursing programs encounter during a time of a global nursing shortage.
Research supports how PAL has the potential to increase a student's confidence within the clinical setting, enhance cognitive and skill practices, and create a safe learning environment (Gabriele, Holthaus, & Boulet, 2016; Speyer, Pilz, Van Der Kruis, & Brunings, 2011; Valler-Jones, 2014). Nursing students embrace this student-centered SBL experience (SBLE) as the approach affords opportunities to cultivate critical thinking among peers, increases leadership and teaching, and enhances knowledge and practice development (Wane & Lotz, 2013; Williams, McKenna, French, & Dousek, 2013). PAL also has the capacity to serve as an extension for faculty whereby peer mentors can identify low-performing students who would require remediation (Gabriele et al., 2016).
An additional consideration for faculty is how increased levels of anxiety negatively affect the ability of a prelicensure nursing student to gain academic success with didactic or clinical education requirements (Gibson, 2014). Although test anxiety produces low performance on examinations, anxiety experienced in the clinical setting can interrupt essential learning processes necessary to excel in the practice setting. Although efforts such as pet visitation, relaxation techniques, and online comprehensive review programs are incorporated to reduce test anxiety, how varied SBL strategies are perceived by prelicensure nursing students are relevant to both full-time and clinical adjunct faculty preparing students for successful entry into the practice setting (Corrigan-Magaldi, Colalillo, & Molloy, 2014; Simon, McGinniss, & Krauss, 2013). Moreover, these same students will soon enter the workforce where not only knowledge but also practice skills necessary to provide safe patient care are vital. The literature underscores the need to more fully understand approaches that promote student success. Student perception of teaching strategies such as PAL is a crucial component to explore, particularly in relation to impact on testing readiness.
This article reports how one pilot project explored prelicensure baccalaureate nursing students' perceptions of PAL combined with SBLE to prepare for and enhance readiness for programmatic exit and national examinations. The specific research questions were:
- Do programmatic examination exit scores, anxiety scores, and satisfaction preference in learning of prelicensure nursing students change following PAL with SBLE?
- What are the perceptions of prelicensure baccalaureate nursing students of PAL with SBLE as a teaching modality to enhance preparedness and readiness to take programmatic exit and national RN examinations?
Design and Sample
A convergent parallel mixed-methods study design was used to address the research questions (Creswell & Plano-Clark, 2011). A nonprobability, convenience purposive sampling method was used to select eligible prelicensure nursing students enrolled in a final transition into practice course during their second-semester senior year. All participants met inclusion criteria of (a) being enrolled as a second- or final-semester senior, (b) willing to complete a baseline Health Education Systems, Inc. (HESI™) medical–surgical speciality examination, and (c) a self-report of receiving a minimum score on the HESI medical–surgical specialty examination (a minimum score was identified as any score below the study site benchmark score of 900). PAL teaching assistants (TAs) were (a) recommended by faculty, (b) demonstrated interest in the role, and (c) attended educational sessions regarding their role within the study. The TAs were also from the same second- or final-semester senior students participating in the study. Participants and PAL TAs were recruited face to face. Study procedures took place in the simulation laboratory setting located on the campus of a school of nursing located in located in the western part of the United States.
Pilot project processes were initiated after (a) approval of the Baylor University Institutional Review Board, (b) processes of informed consent, and (c) identification and training of PAL TAs. Participants completed a baseline HESI medical–surgical specialty examination prior to attending PAL SBLE sessions. Didactic theory remediation topics identified by faculty and verified from participants' baseline HESI examinations served as PAL educational content. National League for Nursing Simulation in Nursing Education Scenarios and Standards of Best Practice: Simulation (INACSL, 2016) were used for the simulation sessions. The topical content included the following: Acute Myocardial Infarction, Acute Cerebral Vascular Accident, Client With Gastrointestinal Bleeding, Client With Acute Respiratory Distress, and a Client With Spiritual Needs. Participants attended five PAL with SBLE sessions lasting approximately 1 hour, scheduled every other week during the semester. Student groups were divided into groups of four to six participants with assigned PAL TAs for the duration of the study.
Demographic Data Survey
A self-report demographic data survey was completed on study entry. Items included age, gender, and preferred learning style.
State-Trait Anxiety Inventory (STAI)
The STAI was administered to measure state anxiety related to examination preparedness and readiness. The STAI for adults (Spielberger, 2015) is designed to measure participant feelings of anxiety at a specific point in time. Comprising 20 items rated on a 4-point Likert-type scale, STAI response categories range from 1 (not at all) to 4 (very much so) with summated scores ranging from 20 to 80; higher scores indicate greater anxiety. The instrument has established reliability with internal consistency alpha coefficients reported as. 86 to. 95 (Julian, 2011). Content validity demonstrated correlations from. 73 to. 85 between the STAI with other personality measurement tools (Julian, 2011; Spielberger, 2015).
Clinical Teaching Preference Questionnaire
The Clinical Teaching Preference Questionnaire (CTPQ) consists of 10 items rated on a 5-point Likert-type scale. The CTPQ is designed to measure respondent teaching preferences (Iwasiw & Goldenberg, 1993) with established reliability and construct validity. Cronbach alpha of. 92 has been reported with internal consistency of items ranging from. 70 to. 89 (Williams et al., 2013). Factor analysis with oblique oblimin rotation resulted in two factors of peer supervision and instructor supervision. Response categories range from 1 (strongly disagree) to 5 (strongly agree) with a possible score ranging from 10 to 50, with higher scores indicating the extent of participant teaching preference.
Programmatic and National Licensure Examination Scores
Participants in this study were administered a HESI medical–surgical specialty examination pre- and post-PAL SBLE. A standard benchmark cutoff of 900 or above was set as a passing score (Elsevier, 2017). First-time pass rates for the NCLEX-RN® were identified postgraduation.
Focus Group Interviews
A principal investigator (PI; K.L.R.)–developed interview guide as per guidelines offered by Creswell and Plano-Clark (2011) was used to collect qualitative data (Table A; available in the online version of this article). Creswell and Plano-Clark (2011) interview techniques were followed to include conducting a focus group interview, audiotaping the interview, and subsequent transcription of the interviews.
All participants completed the demographic data survey and a baseline STAI (Spielberger, 1983) prior to attending the first PAL SBLE session. A prestudy briefing for each session included a brief patient history, objectives, and the roles of the study participants. During the PAL SBLE sessions, participants had access to the client chart complete with history, physical, order sets, laboratory values, and nursing notes. Throughout the PAL SBLE sessions, the PI was in the simulation laboratory control room to manage the technology and voice component involved with running the simulator manikin for the selected scenario. Debriefing was conducted after each SBLE session by the PAL teaching assistant using the scenario-specific debriefing guides. The PI also was present to assist as a mentor during the debriefing. The HESI, STAI, and CTPQ were administered following the five PAL SBLE sessions (Iwasiw & Goldenberg, 1993; Spielberger, 1983). Qualitative data were collected with a digital audiorecording device face to face during focus group interviews within their assigned PAL SBLE study group. The interviews were conducted in a manner in which insight was gained as to the participants' experiences to align with hermeneutic phenomenology (Streubert & Carpenter, 2011). The interviews were transcribed verbatim, and participants were provided an opportunity to review their focus group transcript for accuracy.
Prior to data analysis, data were explored for any missing values with minimal missing data noted. Nominal and ordinal data were examined with frequencies and percentages. Normality testing was conducted. Secondary to small sample size, conducting parametric/nonparametric statistical analysis for the study instruments was not probable. Quantitative data were analyzed using SPSS® version 24. Procedural steps of naïve reading, structural analysis, and interpretation of the whole aligning with hermeneutic phenomenology were used for analysis of qualitative data (Streubert & Carpenter, 2011).
A total of 37 participants (36 women, 1 man) started the study, with a total of 17 participants (N = 17 women) completing all study procedures for an overall attrition rate of 46%. It was noted that, during the study time frame, 112 students demonstrated interest in participating in the study as they completed the pre-HESI medical–surgical specialty examination as part of inclusion criteria. Of those 112 potential participants, 37 attended the first PAL SBLE session and 17 completed the required study procedures to account for the attrition rate. The following are ranges represent the participants who started the study: (a) 20 to 27 years (n = 33), (b) 28 to 37 years (n = 2), and (c) 38 to 47 years (n = 2). Of this population, 15 participants in the age group of 20 to 27 years and two participants in the age group of 38 to 47 years finished all study procedures. Overall learning style preferences included 59.5% kinesthetic, 3.8% visual, and 2.7% auditory. A total of four PAL teaching assistants participated (two each semester).
HESI, STAI, and CTPQ Scores
Means and standard deviation for baseline and post-PAL simulation for HESI scores and STAI are presented group are presented as Group 1 (fall semester cohort, n = 4) and Group 2 (spring semester cohort, n = 13). Group 1 HESI baseline scores of 793 (103) and post-PAL scores of 904 (59) and Group 2 HESI baseline scores of 842 (127) and post-PAL scores of 992 (104) demonstrated an increase in HESI scores. First-time pass rates among all participants was 100% for the NCLEX-RN. When examining STAI scores, Group 1 STAI baseline values of 42.3 (10.7) and post-PAL values of 44.5 (8.9) demonstrated a slight increase in anxiety. By comparison, Group 2 STAI baseline values of 48.6 (12.5) and post-PAL values of 38.84 (10.0) demonstrated a decrease in anxiety. The CTPQ data analysis, which consisted of teaching preferences based on whether an instructor (Figure 1) or a student-peer provided the learning (Figure 2), is presented as combined group scores.
Clinical Teaching Preferences Questionnaire: Instructor Preference.
Clinical Teaching Preference Questionnaire: Peer Learning Preference.
Perceptions of PAL
The three themes of Leveling Within Practice, Gaining Exposure to Teamwork, and Sitting on the Fence With Readiness and Transition were revealed during the qualitative analysis process. A convergence of the qualitative and quantitative data was noted to occur with the HESI, STAI, and CTPQ. The Leveling Within Practice theme aligned with the STAI by comments of “I didn't have this anxiety of having an instructor by me and thinking in my head, ‘Are you doing it right?’” “It's a calmer environment,” and “Your peer explains it a little better to you” highlighted how PAL offers an environment conducive for learning. Responses of “It helped me with testing [and] testing anxiety” and “It's more like helping me understand my thoughts correctly” spoke toward how PAL assisted with decreasing anxiety related to examination preparedness.
Participants' perceptions related to the themes of Leveling Within Practice and Gaining Exposure to Teamwork also converged with the CTPQ with such remarks as “I got feedback from someone who was in the same level as me,” and “Having someone who is at the same level as you…I felt I was freer to ask questions” demonstrated feeling a sense of support during the PAL sessions. In addition, comments such as “You develop a trust and reliance on that person and you kind of know how they operate,” “There's a lot of benefits in group work. It's a team effort getting to learn how to work as a team,” and “Communication and thinking out loud happen…a lot of teamwork” aligned with how participants thought that the PAL sessions offered an opportunity to collaborate and communicate as a member of a team.
For the HESI, Sitting on the Fence With Readiness and Transition emerged with comments of “[The peer teacher] did a really good job of using connections that we've learned in class or in clinical…a role to really teach and pour into the students” and “Simulation took different characteristics and components the NCLEX… that has decreased my anxiety toward the HESI” aligned with the HESI pre- and post-PAL scores. Additionally, remarks of “Simulation and the [PAL] did help to bring it life…. I feel like I'm ready” and “Transitioning our knowledge that we've learned in class and textbooks to actual patients…[is] really helpful toward just nursing practice” afforded a glimpse as to how students are still organizing their preparedness to enter the practice setting.
Anxiety-producing challenges for many prelicensure nursing students may stem from the knowledge as to how entry into practice in the role of a generalist nurse depends on not only achieving a passing score on a programmatic exit examination but also successful completion of an RN licensure examination. Although a small sample size affected the ability to conduct parametric/nonparametric statistical analysis for the study instruments, the STAI scores for both groups suggest the need for both didactic and clinical faculty to remain cognizant of student anxiety. Qualitative data also reinforced how faculty need to be mindful of the influence of prior education with and student perceptions of simulation when considering using SBLE in such a manner. Furthermore, SBLE with PAL offers a medium to address all learning styles, especially kinesthetic learners, where experiential learning can successfully engage the learner to enhance success during nursing school and postgraduation (Brannan, White, & Long, 2016; Li et al., 2014).
Descriptive statistics from the CTPQ factors related to peer learning preference suggest how students are less anxious to learn from a student peer, gained more exposure to teamwork processes through collaboration and communication, and received peer support, which provided some students with additional self-confidence in both didactic theory and clinical skill knowledge (Figures 1–2). The CTPQ factors related to instructor preference align with the literature and suggest that students were able to learn clinical content and feel greater responsibility to carry out clinical skills with the faculty instructor (Cooper, Martin, Fisher, Marks, & Harrington, 2013). Qualitative themes resonated as to how being on the same level of a peer and gaining exposure to teamwork during the PAL SBLE sessions provided participants with the capacity to self-analyze preparation and readiness for upcoming examinations. New graduate nurses entering the practice setting also experience anxiety with professional identities, knowledge of practice area, and competency skills while transitioning into the health care setting (Ewertsson, Bagga-Gupta, Allvin, & Blomberg, 2017). Knowing clinical learning preferences of newly licensed nurses can significantly influence the way hospital educators orient and construct nurse internship programs for successful transition into the workforce.
Although the research processes of this pilot project occurred over two semesters, sample size was identified as a limitation. Among the 171 students enrolled during the study period, 112 students demonstrated an interest in the study by participating in the HESI baseline medical–surgical specialty examination. Despite high interest, placement during the second-semester senior year competed with other student priorities, such as preparation for examinations, employment scheduling, and postgraduation job interviews. Students provided a self-report of their pre-HESI medical–surgical examination; additional participants might have met the study criteria, but chose not to participate. Previous SBLE sessions within the undergraduate curriculum may also have influenced the decision to participate. In addition, this study was conducted at one school of nursing, which can impact generalizability.
Findings from this research project demonstrate how prelicensure nursing students, despite experiencing varied levels of anxiety, are ready to engage in PAL strategies that incorporate SBLE to gain additional preparation for both programmatic and licensure examinations. In an era where hospitals are onboarding newly licensed nurses with SBLE, hospital educators and specialists in the health care industry can look to the literature on anxiety and teaching preferences to determine opportunities to integrate SBLE into existing transition into practice programs.
Recommendations for future research exploring the use of SBLE in a PAL format would include a multisite research study as a way to not only increase sample size but also to capture a more heterogeneous sample. Collecting data from the perspective of students in the role of teaching assistant would be beneficial and enhance overall programmatic effectiveness. In addition, exploration of how learning styles influence learning with this combined strategy would be of value. In a time of a global nursing shortage, research capturing on return on investment of combining PAL with SBLE could influence strategies for remediation and workload for faculty in both academia and within the practice setting during the training of nursing professionals. Finally, incorporating feedback from both students and leadership in the health care setting related to how PAL with SBLE impacted the preparedness and ability of newly licensed nurses to transition into the practice setting would be of use for future programmatic development.
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Introduction to the Interview (approximately 10 minutes)
Introduction of Principal Investigator and Study
You are invited to participate in a research study that will examine if peer-assisted learning with human patient simulation is an effective teaching modality to prepare you for and enhance your readiness to take the NCLEX-RN™ examination. This study seeks to determine what it meant for you to participate in peer assisted learning with simulation sessions and gain insight as to your perceptions of peer assisted learning with human patient simulation as a teaching strategy. You have been chosen as a study participant as you are a second semester senior prelicensure baccalaureate nursing student enrolled in the XXX course. You have the right to leave this study at any time as your participation is voluntary. This study will offer an opportunity to collect more information about peer-assisted learning with human patient simulation.
I am going to ask you some questions pertaining to your experience. To collect your responses accurately, I will digitally audiorecord and write down comments throughout this interview. To ensure confidentiality and anonymity, you name will not be associated with any recorded or written comments.
Interview Questions (approximately 45 minutes)
Tell me about your peer-assisted learning with simulation experience(s).
What did you like the most?
What did you like the least?
What were the most beneficial aspects of learning with a peer as a teacher?
Tell me about your perception of peer-assisted learning with simulation as a teaching strategy
Tell me your perceptions on how peer-assisted learning with simulation assisted with:
Satisfaction in learning
Preparation to take the HESI™ examination
Tell me your perceptions on peer-assisted learning with simulation to enhance your readiness to take the NCLEX-RN examination.
Please provide me with any more details you wish to share about your experiences with peer-assisted learning with simulation.
Interview Closure (approximately 5 minutes)
Summarize Discussion Questions and Responses
Gather any Clarifications from Participants
Thank the students for participating. Let them know this principal investigator will maintain their confidentiality. The potential exists to obtain interview clarifications, which will remain confidential. Participants can request a copy of any findings from the study.